2021, vol. 1 (s4) 15-16 https://doi.org/10.47488/dhrp.v1is4.27 http://dhrproceedings.org 15 © dhr health institute for research and development editorial natural vs. vaccine mediated covid-19 immunity scientific justification to mandate vaccination of recovered healthcare workers to protect the vulnerable patients, many healthcare facilities (including dhr health system) have mandated covid-19 vaccination of its healthcare workers, vendors, contractors, students, residents, and fellows. this policy has been widely debated and it has been suggested that healthcare facilities should adopt a different policy for workers who have recovered from natural sars-cov-2 infection and a waiver should be granted to them as far as covid-19 vaccination mandates are concerned. it has been argued that individuals who have been previously infected with sars-cov-2 virus have acquired immunity which should provide protection against re-infection and therefore they are at a lower risk for the patient. in the united states, over 40 million people have been infected with sars-cov-2 and over 378 million doses of covid-19 vaccines have already been administered (1). some people with covid19 have very mild symptoms and they may see natural infection as preferable to receiving the covid-19 vaccine. additionally, there are some people who are concerned that getting a covid-19 vaccine could make them sicker if they do ultimately get covid-19. it is incontrovertible that getting infected with sars-cov-2 may offer some natural protection. current evidence suggests that reinfection with the sars-cov-2 is uncommon in the 90 days after initial infection. however, it is unclear as to how long this protection lasts, and the risk of severe illness and death from covid-19 far outweighs any benefits that are afforded by natural immunity (2). it was therefore recommended that even people who have been previously infected with sars-cov-2 must consider getting vaccinated. in an independent study, sera obtained from recovered and naïve donors collected prior to, and following immunizations with existing mrna vaccines, was tested to determine its neutralizing capacity against the wild-type and the sars-cov2 variant (3). pre-vaccination sera from recovered donors neutralized the wild type but only intermittently neutralized the variant. on the contrary, a single dose of immunization boosted neutralizing titers against the receptor binding domain of both the variant and the wild type by up to 1000-fold. this study underscores the importance of vaccinating both uninfected and previously infected persons to elicit cross-variant neutralizing antibodies. the fact that vaccinated individuals are at reduced risk of infection as compared to patients who have recovered from sars-cov-2 infection was also confirmed by another case-control study (4). covid-19 infections in kentucky among people who were previously infected with sar-cov-2 shows that unvaccinated individuals are more than twice as likely to be reinfected with covid-19 than those who were fully vaccinated after initially contracting the virus. this data further indicates that covid-19 vaccines offer better protection than natural immunity alone and that vaccines, even after prior infection, help prevent reinfections. the rapid spread of the delta variant and the real potential for continued emergence of more transmissible and infectious sars-cov-2 mutations because of hesitancy in getting vaccinated poses a serious national challenge which demands implementation of an urgent plan of action. consequently, on thursday, september 09, 2021, the u.s., president issued a bold and aggressive plan entitled: path out of the pandemic: president biden’s covid-19 action plan (5). this plan has six distinct initiatives which, when successfully implemented would markedly reduce the risk associated with the spread of sars-cov-2 variants. under the dhrp, 2021, vol. 1 (s4) 15-16 editorial http://dhrproceedings.org 16 © dhr health institute for research and development initiative entitled “vaccinating the unvaccinated”, the following mandates were communicated: • requiring all employers with 100+ employees to ensure their workers are vaccinated or tested weekly • requiring vaccinations for all federal workers and for millions of contractors that do business with the federal government • requiring covid-19 vaccinations for over 17 million health care workers at medicare and medicaid participating hospitals and other healthcare settings • calling on large entertainment venues to require proof of vaccination or testing for entry • requiring employers to provide paid time off to get vaccinated while vaccinating recovered and naïve healthcare workers is essential, this mandate must be implemented ethically ensuring that healthcare workers fully understand both the empirical and moral rationale for the mandatory vaccination program. simply imposing a mandate without laying the ethical groundwork is likely to result in measurable challenges. a prudently developed process must include educational and promotional campaigns to enhance healthcare worker’s knowledge and understanding of the complex and rapidly evolving science related to covid-19. this may include organizing townhall meetings with relevant experts in a forum that allows the healthcare workers to ask questions anonymously. furthermore, this mandate must be anchored on the compelling patient safety concerns and an opt-out criteria based on legitimate and verifiable religious beliefs or medical condition should be made available to the healthcare workers. to ensure its widespread acceptance, mandatory vaccination policies should be transparent and impartial ensuring that it is equally applicable to all members of the healthcare fraternity. lastly, healthcare facilities should make every attempt to provide vaccinations that are free of charge and easily accessible. in conclusion we recommend that based on available scientific evidence, existing u.s. centers for disease control & prevention policies, and in the best interest of the patients, health care facilities are justified in requiring all its employees, vendors, contractors, and learners to be vaccinated even if they have recovered from previous infection with sars-cov-2. references 1. johns hopkins coronavirus resource center. covid-19 dashboard. https://coronavirus.jhu.edu/map.html (accessed september 12, 2021; 22:19 hrs). 2. centers for disease control & prevention. answering patients’ questions about covid-19 vaccine and vaccination. https://www.cdc.gov/vaccines/covid-19/hcp/answeringquestions.html 3. stamatatos l, czartoski j, wan yh, homad lj, rubin v, glantz h, neradilek m, seydoux e, jennewein mf, maccamy aj, feng j, mize g, de rosa sc, finzi a, lemos mp, cohen kw, moodie z, mcelrath mj, mcguire at. mrna vaccination boosts cross-variant neutralizing antibodies elicited by sarscov-2 infection. science. 2021 mar 25: eabg9175. doi: 10.1126/science. abg9175. epub ahead of print. pmid: 33766944; pmcid: pmc8139425. 4. cavanaugh am, spicer kb, thoroughman d, glick c, winter k. reduced risk of reinfection with sars-cov-2 after covid19 vaccination – kentucky, may – june 2021. mmwr morb mortal wkly rep 2021; 70: 1081-1083. https://www.cdc.gov/mmwr/volumes/70/wr/mm7032e1.htm?s _cid=mm7032e1_w 5. path out of the pandemic: president biden’s covid-19 action plan. sept. 09, 2021. https://www.whitehouse.gov/covidplan/ sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 manish singh, md, facs chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas disclosures: none orcid: manish singh: https://orcid.org/0000-00034146-3282 https://coronavirus.jhu.edu/map.html https://www.cdc.gov/vaccines/covid-19/hcp/answering-questions.html https://www.cdc.gov/vaccines/covid-19/hcp/answering-questions.html https://www.cdc.gov/mmwr/volumes/70/wr/mm7032e1.htm?s_cid=mm7032e1_w https://www.cdc.gov/mmwr/volumes/70/wr/mm7032e1.htm?s_cid=mm7032e1_w https://www.whitehouse.gov/covidplan/ https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0003-4146-3282 https://orcid.org/0000-0003-4146-3282 2021, vol. 1 (s5) 1-3 https://doi.org/10.47488/dhrp.v1is5.31 http://dhrproceedings.org 1 © dhr health institute for research and development editorial is there any advantage of using polyclonal vs. monoclonal antibodies for passive enhancement of immunity in patients with covid-19? on november 08, 2020, the us food & drug administration (fda) approved the use of first monoclonal antibody – bamlanivimab (lycov555; eli lilly & company) for the treatment of high-risk patients with mild-moderate sars-cov2 infection (1). subsequently, on november 23, 2020, fda approved another cocktail of monoclonal antibodies – casirivimab + imdevimab (regen-cov; regeneron pharmaceuticals) for use in a similar cohort of high-risk patients with mild-moderate covid-19. since the initial emergency use authorizations (eua), fda has made numerous modifications/amendments including revoking the authorization for monotherapy with bamlanivimab (3); addition of etesevimab to bamlanivimab monotherapy; and authorization of another monoclonal antibody – sotrovimab (xevudy; glaxo, smith & kline) (4), the primary objective of these emergency authorizations was to treat patients early in the course of the disease in an non-hospitalized setting thus mitigating the progression of covid-19 to a more severe stage that would necessitate hospitalization. with the availability of these monoclonal antibodies, we at dhr health proceeded to obtain approval of a prospective study from the dhr health institute for research & development institutional review board to treat high-risk patients with mild-moderate covid-19. the first patient was treated on november 25, 2020, and since then, we have infused anti-sars-cov-2 monoclonal antibodies in over 580 patients with very satisfactory outcomes. this included both patients who had mild-moderate sars-cov-2 infection as well for post-exposure prophylaxis in covid-19 negative subjects. while effective, monoclonal antibodies have inherent advantages and disadvantages when used for therapeutic purposes. produced in vitro from immortalized plasma cells, monoclonal antibodies have single specificity and affinity which, reduces the probability of cross reactivity (figure 1). due to batch-to-batch homogeneity, effectiveness of monoclonal antibodies is much more predictable, and they serve as an ideal candidate for use in diagnostic immunoassays. a distinct disadvantage of monoclonal antibodies is the fact that due to its high specificity and affinity, a minor mutation in the epitope often renders the antibody ineffective in neutralizing the target. this is a serious limitation since observed mutations in sars-cov-2 with generations of numerous variants may render the available monoclonal antibodies less effective in mitigating the progression of covid-19. on the contrary, polyclonal antibodies are a mixture of monoclonal antibodies that are products of multiple b cell clones. generated in animals, polyclonal antibodies recognize with reasonably high affinity multiple epitopes on a single antigen (figure 1). this affords polyclonal antibodies a distinct advantage over monoclonal antibodies when used as therapeutic agents particularly in patients infected with rapidly mutating sarscov-2 virus. figure 1: monoclonal antibody have affinity for a single epitope on the antigen (i.e., the virus or the bacteria). on the contrary, polyclonal antibodies are a mixture of monoclonal antibodies with affinity for various epitopes on the antigen. dhrp, 2021, vol. 1 (s5) 1-3 editorial http://dhrproceedings.org 2 © dhr health institute for research and development on april 17, 2020, the national institutes of health (nih) announced the accelerating covid-19 therapeutic interventions and vaccines (activ) public-private partnership to develop a coordinated research strategy for prioritizing and speeding development of the most promising treatments and vaccines. activ was based on bayesian adaptive clinical trial design which allows for frequent “looks” at the data and permits data-driven modifications during the course of the study (5). dhr health institute for research and development is part of the activ collaborative and have initiated numerous studies in an attempt to find the most promising therapeutic agent to prevent and/or treat patients with covid-19. as part of activ-2, dhr health institute for research & development has initiated a prospective phase 2/3 clinical trial to evaluate the efficacy of fully human anti-sars-cov-2 polyclonal antibody (sab-185; sab pharmaceuticals, inc.) to treat unvaccinated nonhospitalized high-risk patients with mild-moderate covid-19. sab-185 is a fully human, anti-sarscov-2 immunoglobulin produced in transchromosomic bovines (tc-higg-sars-cov2) hyperimmunized with two doses of plasmid dna encoding the sars-cov-2 wuhan strain s gene, followed by repeated immunization with s protein purified from insect cells (6,7). the resulting tc-higg-sars-cov-2, termed sab-185, efficiently neutralizes sars-cov-2, and vesicular stomatitis virus (vsv) sars-cov-2 chimeras in vitro. this fully human polyclonal antibody that potently inhibits sars-cov-2 infection may provide an effective therapeutic agent to combat covid-19. this is not a placebo-controlled study as the patients in the comparator arm will be treated with regen-cov monoclonal antibody. in conclusion, the use of available anti-sars-cov2 monoclonal antibodies has been effective in mitigating the progression of disease in high-risk patients with mild-moderate covid-19. however, it could be argued that the use of fully human polyclonal antibodies with affinity for multiple epitopes on sars-cov-2 may be more effective in eliminating the virus and its variants which exhibit higher transmissibility, infectivity, and the potential to “escape” from the neutralizing effects of existing experimental agents. references 1. emergency use authorization (eua) for bamlanivimab 700mg iv center for drug evaluation and research (cder) review. 2020. https://www.fda.gov/media/144118/download (accessed october 26, 2021). 2. emergency use authorization for regen-cov for the treatment of mild-moderate covid-19. 2020. https://www.fda.gov/media/145610/download . (accessed october 26, 2021). 3. fda revokes initial emergency use authorization of monotherapy with bamlanivimab. march 2021. https://www.fda.gov/media/143602/download (accessed october 27, 2021). 4. fda authorizes additional monoclonal antibody for treatment of covid-19. 2021. https://www.fda.gov/newsevents/press-announcements/coronavirus-covid-19-update-fdaauthorizes-additional-monoclonal-antibody-treatment-covid-19 . (accessed october 27, 2021). 5. giovagnoli a. (2021). the bayesian design of adaptive clinical trials. international journal of environmental research and public health, 18(2), 530. https://doi.org/10.3390/ijerph18020530 6. gilliland t, liu y, li r, dunn m, cottle e, terada y, rickman z, alcorn m, vasilatos s, lundy j, larson d, wu h, luke t, bausch c, egland k, sullivan e, wang z, klimstra wb. protection of human ace2 transgenic syrian hamsters from sars cov-2 variants by human polyclonal igg from hyperimmunized transchromosomic bovines. biorxiv [preprint]. 2021 jul 26:2021.07.26.453840. doi: 10.1101/2021.07.26.453840. pmid: 34341790; pmcid: pmc8328057. 7. liu z, wu h, egland ka, gilliland tc, dunn md, luke tc, sullivan ej, klimstra wb, bausch cl, whelan spj. human immunoglobulin from transchromosomic bovines hyperimmunized with sars-cov-2 spike antigen efficiently neutralizes viral variants. hum vaccin immunother. 2021 jul 6:1-10. doi:10.1080/21645515.2021.1940652. epub ahead of print. pmid: 34228597; pmcid: pmc8290372. sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 https://www.fda.gov/media/144118/download https://www.fda.gov/media/145610/download https://www.fda.gov/media/143602/download https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-monoclonal-antibody-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-monoclonal-antibody-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-monoclonal-antibody-treatment-covid-19 https://doi.org/10.3390/ijerph18020530 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 dhrp, 2021, vol. 1 (s5) 1-3 editorial http://dhrproceedings.org 3 © dhr health institute for research and development caitlin white dhr health institute for research & development, 5323 s. mccoll road, edinburg, tx 78539. disclosures: none orcid: caitlin white: https://orcid.org/0000-00015528-2242 manish singh, md, facs chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas dhr health bariatric & metabolic institute, 5500 raphael drive, edinburg, tx 79539 disclosures: none orcid: manish singh: https://orcid.org/0000-00034146-3282 https://orcid.org/0000-0001-5528-2242 https://orcid.org/0000-0001-5528-2242 2021, vol. 1 (s5) 7-10 https://doi.org/10.47488/dhrp.v1is5.35 http://dhrproceedings.org 7 © dhr health institute for research and development commentary the newly detected b.1.1.529 (omicron) variant of sars-cov-2 with multiple mutations implications for transmission, diagnostics, therapeutics, and immune evasion sohail rao, md, ma, dphil1, 2 and manish singh, md, facs3 1 executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas 78539 and president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0001-5027-9992 2 correspondence should be addressed to: sohail rao, md, ma, dphil., dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. tel: (956) 362-2387. e-mail: s.rao@dhr-rgv.com 3 chief executive officer, dhr health, 5501 s. mccoll road, edinburg tx 78539 and dhr health bariatric and metabolic institute, 500 raphael drive, edinburg, tx 78539 orcid: manish singh: https://orcid.org/0000-0003-4146-3282 received 11/27/2021 accepted for publication 11/29/2021 published 11/29/2021 keywords: covid-19; sars-cov-2; b.1.1.529; omicron variant; vbm: variant being monitored; voi: variant of interest; voc: variant of concern; vohc: variant of high concern; sdft: s-gene target failure; ace2: angiotensin-converting enzyme 2; cdc: center for disease control and prevention the global and regional impact of sars-cov-2 pandemic continues to be a source of grave concern. while the availability of vaccines against the sars-cov-2 virus may have partially assuaged this anxiety in certain parts of the world, it remains a prevailing and unpretentious global public health crisis. the latter outcome is fueled by the convergence of several factors which include (but not limited to) the lack of availability of adequate number of vaccines; poor socioeconomic conditions; vaccine hesitancy; and rampant proliferation of misinformation on the social media. to date, sars-cov-2 pandemic has infected over 48 million people in the united states resulting in the death of over 777 thousand (1). it is noteworthy that to a large extent, refusal by hominoid to get vaccinated in the united states continues to be a source of much consternation. not only do unvaccinated people have a much higher rate of infection and hospitalization, but they are also a very fertile source for generation of sars-cov-2 variants. since the identification of the first infected case of covid-19 in wuhan, china in december 2019, the world has witnessed multiple peaks of resurgence of covid-19 pandemic largely as a consequence of mutations in the sars-cov-2 with enhanced transmissibility and infectivity. the us sars-cov-2 interagency group (sig) has delineated sars-cov-2 variants into four distinct categories (table 1). to date, the most impactful in terms of its transmissibility and infectivity has been the delta (b.1.617.2) variant of sars-cov-2. first identified in india in december 2020, the delta variant swept rapidly through that country and great britain before reaching the u.s., where it quickly surged. it is now the predominant sars-cov-2 variant, accounting for more than 99% of covid-19 cases and leading to an overwhelming increase in hospitalizations in some states (2). the delta variant was believed to be more than five times as contagious as previous variants, and studies have shown that it may be more likely than the original virus to put infected people in the hospital. people who are not vaccinated are most at risk, and the highest spread of cases and severe outcomes is happening in states with low vaccination rates. https://orcid.org/0000-0001-5027-9992 mailto:s.rao@dhr-rgv.com https://orcid.org/0000-0003-4146-3282 dhrp, 2021, vol. 1 (s5) 7-10 the b.1.1.529 (omicron) variant of sars-cov-2 http://dhrproceedings.org 8 © dhr health institute for research and development table 1: us government sars-cov-2 interagency group classification of sars-cov-2 variants (as of november 26, 2021; 1400 hrs.) classification definition variants identified variant being monitored (vbm) variant for which there is data indicating a potential or clear impact of approved or authorized medical countermeasures; or that has been associated with more severe disease or increased transmission but are no longer detected or are circulating at very low levels in the united states, and as such, do not pose a significant and imminent risk to public health in the united states. • alpha (b.1.1.7 and q lineages) • beta (b.1.351 and descendent lineages) • gamma (p.1 and descendent lineages) • epsilon (b.1.427 and b.1.429) • eta (b.1.525) • iota (b.1.526) • kappa (b.1.617.1) • 1.617.3 • mu (b.1.621, b.1.621.1) • zeta (p.2) variant of interest (voi) variant with specific genetic markers that have been associated with changes to receptor binding; reduced neutralization by antibodies generated against previous infection or vaccination; reduced efficacy of treatments; potential diagnostic impact; or predicted increase in transmissibility or disease severity • none variant of concern (voc) variant for which there is evidence of an increase in transmissibility; more severe disease (e.g., increased hospitalizations or deaths); significant reduction in neutralization by antibodies generated during previous infection or vaccination; reduced effectiveness of treatments or vaccines; or diagnostic detection failures • delta (b.1.617.2 and ay lineages) • omicron (b.1.1.529) variant of high consequence (vohc) variant of high consequence has clear evidence that prevention measures or medical countermeasures (see below) have significantly reduced effectiveness relative to previously circulating variants. possible attributes of a variant of high consequence (in addition to the possible attributes of a variant of concern): • demonstrated failure of diagnostic test targets • evidence to suggest a significant reduction in vaccine effectiveness; a disproportionately high number of infections in vaccinated persons; or very low vaccineinduced protection against severe disease • significantly reduced susceptibility to multiple emergency use authorization (eua) or approved therapeutics • more severe clinical disease and increased hospitalizations • none dhrp, 2021, vol. 1 (s5) 7-10 the b.1.1.529 (omicron) variant of sars-cov-2 http://dhrproceedings.org 9 © dhr health institute for research and development on november 13, 2021, thomas peacock, a post-doctoral fellow in the division of infectious diseases, imperial college london, london, united kingdom submitted a sequence to github of a new variant (b.1.1.529) of sars-cov-2 isolated from an immunocompromised patient in south africa (3). according to the available data, the new variant has 32 mutations in the conserved domain of the spike protein which, is the region of the sars-cov-2 that binds to the angiotensin-converting enzyme 2 (ace2) allowing for the conformational change that facilitates its entry into host cells and is the target of immune responses. additionally, 19 mutations were also identified in the conserved non-spike region of the b.1.1.529 variant which, are assumed to be of less significance in terms of the transmissibility and infectivity of the sars-cov-2. while most of the mutations in the spike region of b.1.1.529 were similar to that in the delta variant, some were unique which raised serious concerns about the transmissibility of this variant. in fact, the b.1.1.529 is now the most dominant variant identified in patients with covid-19 in south africa and has already been isolated from patients with covid-19 in other southern african countries (lesotho, botswana, namibia, eswatini and zimbabwe), belgium, israel, and hong kong (5). according to the modelling using s-gene target failure (sdft) data, the rate of infection from the b.1.1.529 will be 100-fold higher as compared to that to the delta variant of sars-cov-2 (figure 1). figure 1: modeling of spread of covid-19 cases in south africa from infection with b.1.1.529 variant of sars-cov-2 using s-gene target failure data* *source: financial times analysis of data from global initiative on sharing avian influenza data (gisaid) and the south african national health laboratory service given these alarming observations, the technical advisory group of the world health organization (who) met on november 26, 2021, and classified the b.1.1.529 as the variant of concern and named it “omicron” (6). it is also unclear at this moment if the immunity acquired against sars-cov-2 following natural infection and/or vaccination would be effective against this variant. equally, disconcerting is the possibility that the existing molecular tests that are commonly used to diagnose infection with sars-cov-2 might be less effective in identifying the b.1.1.529 variant. nevertheless, to contain the spread of omicron, united states has banned flights from seven high-risk countries effective monday, november 29, 2021 (7). similar travel restrictions have also been implemented by many other countries around the globe. in conclusion, the identification of a new potentially more dangerous variant is a somber reminder that the world is still living under the umbrella of a pandemic and remains highly vulnerable to another wave of sars-cov-2 infection. despite these travel restrictions, it is only a matter of time that the b.1.1.529 variant will be identified in patients in the us. in fact, we predict that the b.1.1.529 variant has already penetrated the us eco-system. while it must be confirmed unequivocally, given some similarities of observed mutations in b.1.1.529 to that to the delta variant, we envisage that the immune responses raised by the currently available vaccines will be effective in protecting against this variant. it is the degree of protection afforded by these vaccines against omicron which is the focus of studies currently underway. hence the need for universal vaccination all around the world otherwise, the threat of evolving new and more dangerous sars-cov-2 variants will always be lurking in the background. recent affirmative news about the gradual decline in the rate of infection and hospitalization in some states has perhaps bestowed false reassurance prompting many to abandon us centers for disease control & prevention guidelines for limiting the spread of covid-19. it is, therefore, imperative that we continue to exercise extreme caution in our social congregations and all those who are eligible must get vaccinated including the third and/or the booster doses. diclosures sr declares no conflicts of interest. ms declares no conflicts of interest. funding the project is funded by a seed grant from the dhr health institute for research & development references 1. the coronavirus resource center. the johns hopkins university. 2021. https://coronavirus.jhu.edu/map.html . (accessed november 26, 2021, at 13:00 hrs) 2. cdc data tracker. monitoring variant proportions. 2021 https://covid.cdc.gov/covid-data-tracker/#variantproportions ((accessed november 26, 2021, at 14:00 hrs)) https://coronavirus.jhu.edu/map.html https://covid.cdc.gov/covid-data-tracker/#variant-proportions https://covid.cdc.gov/covid-data-tracker/#variant-proportions dhrp, 2021, vol. 1 (s5) 7-10 the b.1.1.529 (omicron) variant of sars-cov-2 http://dhrproceedings.org 10 © dhr health institute for research and development 3. fda authorizes additional monoclonal antibody for treatment of covid-19. 2021. https://www.fda.gov/news-events/pressannouncements/coronavirus-covid-19-update-fdaauthorizes-additional-monoclonal-antibody-treatmentcovid-19 . (accessed november 26, 2021). 4. peacock, t. b.1.1 descendant associated with southern africa with high number of spike mutations. 2021. github. https://github.com/cov-lineages/pangodesignation/issues/343 . 5. cheng, m. what is this new covid variant in south africa. november 26, 2021. associated press. https://www.aol.com/explainer-covid-variant-southafrica-111307372-142856393.html 6. classification of omicron (b.1.1.529): sars-cov-2 variant of concern. world health organization. november 26, 2021. https://www.who.int/news/item/26-11-2021classification-of-omicron-(b.1.1.529)-sars-cov-2variant-of-concern 7. statement from president joe biden on the omicron covid-19 variant. the white house. november 26, 2021. https://www.whitehouse.gov/briefingroom/statements-releases/2021/11/26/statement-bypresident-joe-biden-on-the-omicron-covid-19-variant/ https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-monoclonal-antibody-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-monoclonal-antibody-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-monoclonal-antibody-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-monoclonal-antibody-treatment-covid-19 https://github.com/cov-lineages/pango-designation/issues/343 https://github.com/cov-lineages/pango-designation/issues/343 https://www.aol.com/explainer-covid-variant-south-africa-111307372-142856393.html https://www.aol.com/explainer-covid-variant-south-africa-111307372-142856393.html https://www.who.int/news/item/26-11-2021-classification-of-omicron-(b.1.1.529)-sars-cov-2-variant-of-concern https://www.who.int/news/item/26-11-2021-classification-of-omicron-(b.1.1.529)-sars-cov-2-variant-of-concern https://www.who.int/news/item/26-11-2021-classification-of-omicron-(b.1.1.529)-sars-cov-2-variant-of-concern https://www.whitehouse.gov/briefing-room/statements-releases/2021/11/26/statement-by-president-joe-biden-on-the-omicron-covid-19-variant/ https://www.whitehouse.gov/briefing-room/statements-releases/2021/11/26/statement-by-president-joe-biden-on-the-omicron-covid-19-variant/ https://www.whitehouse.gov/briefing-room/statements-releases/2021/11/26/statement-by-president-joe-biden-on-the-omicron-covid-19-variant/ 2021, vol. 1 (s3) 1-2 https://doi.org/10.47488/dhrp.v1is3.13 http://dhrproceedings.org 1 © dhr health institute for research and development editorial the use of transgenic mosquitoes to control vertical transmission of arbovirus-related illnesses the rationale for conducting a field trial in the florida keys and its relevance to south texas globally, mosquitoes – the world’s deadliest animal, infect over 700 million and are responsible for the death of over one million people every year (1). it is estimated that mosquito-borne illnesses account for 17% of the estimated global burden of infectious diseases (2). deadly arboviral diseases transmitted by mosquitoes include (among others) malaria, dengue, west nile virus, yellow fever, zika fever and chikungunya (3). it is common knowledge that male mosquitoes do not bite but rather feed on nectar from flowers. on the contrary, female mosquitoes bite as they need blood to produce eggs (4). of the many species of mosquitoes, aedes aegypti is the primary vector that is responsible for vertical transmission of several arboviral diseases and has been most extensively studied (5). aedes aegypti mosquitoes live in tropical, subtropical and some temperate climate and since they prefer to feed on people, they are most likely to spread arboviral illnesses (6). the efforts of world health organization and the center for disease control and prevention to prevent and/or control mosquito-borne illness have yielded success, but it remains a serious global challenge. more recently, several approaches to create transgenic mosquitoes with the ultimate objective of preventing and/or controlling mosquito-borne illness have undergone field studies. infecting aedes aegypti mosquitoes with different strains of wolbachia resulted in the reduction of egg laying rates and transmission ability and shorter lifespan (7). similarly, using genetic technology, a selflimiting strain of aedes aegypti male mosquitoes (ox513a) when released in the field have shown an 81%-95% suppression of population of this strain as compared to adjacent no-release control field (8). these encouraging results prompted the issuance of authorization by the u.s. environmental protection agency for the use of second generation genetically modified aedes aegypti mosquitoes (ox5034) in florida and texas (9). ox5034 has a self-limiting gene that prevents female aedes aegypti offspring from surviving to adulthood. ox5034 is described as a species-specific female larvicide, or “maleselecting” larvicide, that results in all-male progeny in the absence of tetracycline in the larval diet due to a female specific self-limiting gene. with continued field releases of ox5034 homozygous males, the aedes aegypti population is expected to progressively decline due to the reduced number of females emerging in the area. specifically, when ox5034 homozygous males are released into the environment and mate with wild aedes aegypti females, their offspring inherit a single copy of the self-limiting gene. the self-limiting gene kills only female offspring while hemizygous males survive to pass on the ox5034 self-limiting gene further. as the self-limiting gene is inherited in a mendelian fashion, half of the offspring resulting from a mating between an ox5034 hemizygous male, and a wild female would not inherit the self-limiting gene but would still inherit ox5034 strain genetics. this results in both male and female mosquitoes with ox5034 strain genetics (10). despite public opposition, 750 million ox5034 will be ultimately released in the florida keys an area devastated by mosquito-borne illnesses (11). this will be the first-ever use of genetically modified mosquitoes in the united states. as an initial field experiment, in the week of may 03, 2021, an estimated 150,000 genetically modified eggs of aedes aegypti will hatch in six small areas of ramrod key, cudjoe key and vaca key in florida keys (12). since 2019, over one billion genetically modified mosquitoes have been successfully released in parts of brazil, cayman islands, panama and india to control aedes aegypti (13). in all these dhrp, 2021, vol. 1 (s3) 1-2 editorial http://dhrproceedings.org 2 © dhr health institute for research and development studies, there has been no evidence of any harmful effects on humans, animals and or the environment. considering the available safety data combined with the observed effectiveness of the genetically modified mosquitoes in reducing the burden of arboviral diseases in the community, the decision by the us environmental protection agency was justified. the implications for the success of the use of genetically modified mosquitoes are self-evident and its use must be seriously contemplated for other parts of the nation including south texas the weather of which, is not dissimilar to florida keys. references 1. caraballo h and king k. emergency department management of mosquito-borne illness: malaria, dengue, and west nile virus. emerg med pract. 2014 may;16(5):1-23; quiz 23-4. pmid: 25207355 2. mosquitoes: world’s deadliest animal. barcelona institute of global health. https://www.isglobal.org/en/new//asset_publisher/jz9fgljxnwpi/content/mosquito-el-animalmas-letal-del-mundo 3. mosquito-borne diseases. the national institute for occupational safety and health, centers for disease control and prevention. https://www.cdc.gov/niosh/topics/outdoor/mosquitoborne/default.html 4. mcbride cs, baier f, et.al. evolution of mosquito preference for humans linked to an odorant receptor. nature. 2014 nov 13;515(7526):222-7. doi: 10.1038/nature13964. 5. kamal m, kenawy ma, et.al. mapping the global potential distribution of two arboviral vectors aedes aegypti and ae. albopictus under changing climate. plos one. 2018 dec 31;13(12):e0210122. doi: 10.1371/journal.pone.0210122. ecollection 2018. 6. harrington lc, edman jd and scott tw. 2001. why do female aedes aegypti (diptera:culicidae) feed preferentially and frequently on human blood? journal of medical entomology 38:411-422. 7. xue l, fang z, et al. comparing the effectiveness of different strains of wolbachia for controlling chikungunya, dengue fever, and zika. plos negl trop dis. 2018 jul 30;12(7):e0006666. doi:10.1371/journal.pntd.0006666. ecollection 2018 jul. 8. carvalho do, mckerney ar, et. al. suppression of a field population of aedes aegypti in brazil by sustained release of transgenic male mosquitoes. plos negl trop dis. 2015 jul 2;9(7): e0003864. doi:10.1371/journal.pntd.0003864. ecollection 2015. 9. epa approves experimental use permit to test innovative biopesticide toll to better protect public health. may 01, 2020. https://www.epa.gov/pesticides/epa-approves-experimentaluse-permit-test-innovative-biopesticide-tool-better-protect. 10. significant technology advancements set stage for targeted, multi-generation suppression of disease-transmitting mosquitoes. https://www.oxitec.com/en/news/oxitec-launchesfield-trial-in-brazil-for-next-generation-addition-to-friendlymosquitoes-platform 11. millions of genetically-modified mosquitoes will be deployed to save floridians from bites. https://www.zmescience.com/science/genetically-modifiedmosqito-262345/ 12. first-ever us release of genetically modified mosquitoes begins in florida keys. april 30, 2021. https://www.cnn.com/2021/04/30/health/genetically-modifiedmosquitoes-us-scn-wellness/index.html 13. de andrade pp, aragao fjl, et. al. use of transgenic aedes aegypti in brazil. risk, perception and assessment. bull world health organ 2016 oct 1;94(10):766-771. doi:10.2471/blt.16.173377. epub 2016 aug 31. sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 2021, vol. 1 (s5) 15-17 https://doi.org/10.47488/dhrp.v1is5.39 http://dhrproceedings.org 15 © dhr health institute for research and development commentary growing shortage of healthcare workers poses an existential threat to the public health system strategies to mitigate this challenge in the face of covid-19 pandemic sohail rao, md, ma, dphil1, 2 and manish singh, md, facs3 1 executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas 78539 and president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0001-5027-9992 2 correspondence should be addressed to: sohail rao, md, ma, dphil., dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. tel: (956) 362-2387. e-mail: s.rao@dhr-rgv.com 3 chief executive officer, dhr health, 5501 s. mccoll road, edinburg tx 78539 and dhr health bariatric & metabolic institute, 5500 raphael drive, edinburg, tx 79539 orcid: manish singh: https://orcid.org/0000-0003-4146-3282 received 12/27/2021 accepted for publication 12/29/2021 published 12/29/2021 keywords: covid-19; sars-cov-2; omicron variant; cdc: centers for disease control and prevention; fda: u.s. food and drug administration; evusheldtm the growing shortage of essential healthcare workers has been a chronic challenge worldwide. the covid-19 pandemic has exacerbated this challenge and has undermined the ability of many health systems to continue to offer optimal and timely clinical care to its patients. many factors are responsible for this outcome not to mention the aging healthcare workforce, early retirements due to the covid-19 pandemic, mental and physical exhaustion, lack of strategic planning for workforce retention, and national and international mobility (1-3). collectively, these factors have created an ambiguous future and a precarious disproportion between the demand and supply of essential healthcare workers. the burgeoning primary and breakthrough infections with omicron variant of sars-cov-2 has placed yet additional burden on the healthcare system and its frontline workforce. recognizing this advancing catastrophe, the centers for disease control and prevention (cdc) recently forwarded some guidelines to help assuage the same (4). at the core of these guidelines was the understanding that healthcare organization will:  ensure any covid-19 vaccine requirements for hcp are followed, and where none are applicable, encourage vaccination, including booster dose, as recommended by the cdc (5)  understand their normal staffing needs and the minimum number of staff needed to provide a safe work environment and safe patient care under normal circumstances https://orcid.org/0000-0001-5027-9992 mailto:s.rao@dhr-rgv.com https://orcid.org/0000-0003-4146-3282 dhrp, 2021, vol. 1 (s5) 15-17 shortage of healthcare workers: strategies to mitigate this challenge http://dhrproceedings.org 16 © dhr health institute for research and development  understand the local epidemiology of covid-19related indicators (e.g., community transmission levels)  communicate with local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional healthcare personnel (e.g., hiring additional healthcare personnel, recruiting retired healthcare personnel, using students or volunteers), when needed under these revised cdc guidelines, healthcare workers who either have asymptomatic sars-cov-2 infection and/or higher-risk exposure (6) are allowed to return to onsite work as long as there is strict screening and surveillance protocol in place (table 1). if fully implemented these measures are predicted to have some impact on mitigating the shortage of healthcare workers. however, it is undetermined at this stage if the healthcare workers, members of their families, coworkers, patients, and caregivers would be willing to accept the inherent risk associated with this significant structural change in policy. table 1: cdc guidelines for work restrictions for frontline healthcare workers with sars-cov-2 infections and exposures* *https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staffshortages.html it is abundantly clear that the need to protect the healthcare workers and the environment in which they practice is quintessential to mitigate this crisis. it is also imperative that to continue to retain public trust in our healthcare system, we adopt policies that are widely accepted and easily implemented. it is also perturbing that we have arbitrarily and conveniently segregated healthcare workers into those at high risk of exposure and otherwise. the reality on the ground is that all healthcare workers are at an equally high risk of exposure and therefore must be treated accordingly. however, it is understandable that to gain maximum benefit, we may need to prioritize the implementation and distribution of limited resources. fortunately, we have the tools to accomplish these outcomes without placing undue risk on both the patients and the providers. our recommendations are outlined in figure 1 and briefly iterated herein. in most institutions, the healthcare workforce is vaccinated with at least the two-dose primary vaccination. this followed the mandatory ruling by the centers for medicare and medicaid services requiring that all medicare and medicaid-certified providers and suppliers must be vaccinated, and they must meet this requirement to continue to participate in the medicare and medicaid programs (7). for symptomatic and/or asymptomatic covid-19 positive healthcare workers, we recommend that we follow the recently published cdc guidelines (table 1). on the contrary, every attempt should be made to protect those healthcare workers who are covid-19 negative and prevent breakthrough sars-cov-2 infections in this cohort. in an attempt to accomplish this outcome, we are recommending that the immunity against sars-cov-2 in frontline healthcare workers who are actively engaged in patient care must be passively enhanced by treating them with the recently authorized monoclonal antibody – evusheld tm (8). given the observed long-acting benefit of treatment with this monoclonal antibody, it is postulated that its use would minimize the risk of getting infected with sars-cov-2 (9). additionally, with waning immunity, we are advocating that all healthcare workers must be considered for a 4th dose (or 2nd booster dose) of mrna vaccine at least 90-days after their last booster dose. while still awaiting approval from the ministry of health, the israel’s pandemic response team has already recommended this later protocol providing 4th dose of mrna covid-19 vaccine to all healthcare workers; at-risk people; and those who are >60 years of age (10). figure 1: proposed interventions to mitigate the prevailing shortage of healthcare workers this is a watershed moment in the history of healthcare industry, and it demands that we think innovatively in an attempt to moderate this nascent crisis. the focus of this manuscript was to underscore the impact of covid-19 pandemic on healthcare industry and to propose innovative solutions to mitigate the shortage of healthcare workers. https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html dhrp, 2021, vol. 1 (s5) 15-17 shortage of healthcare workers: strategies to mitigate this challenge http://dhrproceedings.org 17 © dhr health institute for research and development nevertheless, we must continue to address other intractable challenges that are more impactful in developing a long-term sustainable strategy to overcome the burgeoning shortage of frontline healthcare workers. diclosures sr declares no conflicts of interest. ms declares no conflicts of interest. references 1. hall h. the effect of the covid-19 pandemic on healthcare workers' mental health. jaapa. 2020 jul;33(7):45-48. doi: 10.1097/01.jaa.0000669772.78848.8c. pmid: 32590533. 2. turale s, meechamnan c, kunaviktikul w. challenging times: ethics, nursing, and the covid-19 pandemic. int nurs rev. 2020 jun;67(2):164-167. doi: 10.1111/inr.12598. pmid: 32578249; pmcid: pmc7361611. 3. nyashanu m, pfende f, ekpenyong m. exploring the challenges faced by frontline workers in health and social care amid the covid-19 pandemic: experiences of frontline workers in the english midlands region, uk. j interprof care. 2020 sep-oct;34(5):655-661. doi: 10.1080/13561820.2020.1792425. epub 2020 jul 17. pmid: 32674701. 4. strategies to mitigate healthcare personnel staffing shortages. centers for disease control and prevention. https://www.cdc.gov/coronavirus/2019ncov/hcp/mitigating-staff-shortages.html (accessed december 25, 2021; 00:06 hrs cst) 5. interim clinical considerations for use of covid-19 vaccines currently approved or authorized in the united states. centers for disease control and prevention. https://www.cdc.gov/vaccines/covid19/clinical-considerations/covid-19-vaccines-us.html. (accessed december 25, 2021; 00:26 hrs cst) 6. interim guidance for managing healthcare personnel with sars-cov-2 infection or exposure to sarscov-2. centers for disease control and prevention. https://www.cdc.gov/coronavirus/2019ncov/hcp/guidance-risk-assesment-hcp.html. (accessed december 25, 2021; 10:17 hrs cst). 7. medicare and medicaid programs; omnibus covid-19 health care staff vaccination. a rule by the centers for medicare & medicaid services on 11/05/2021. https://www.federalregister.gov/documents/2021/11/05/ 2021-23831/medicare-and-medicaid-programs-omnibuscovid-19-health-care-staff-vaccination 8. coronavirus (covid-19) update: fda authorizes new long-acting monoclonal antibodies for pre-exposure prevention of covid-19 in certain individuals. u.s. food and drug administration. https://www.fda.gov/news-events/pressannouncements/coronavirus-covid-19-update-fdaauthorizes-new-long-acting-monoclonal-antibodies-preexposure. (accessed december 25, 2021; 11:53 hrs cst) 9. fact sheet for healthcare providers: emergency use authorization for evusheld™ (tixagevimab copackaged with cilgavimab). s://www.fda.gov/media/154701/download. (accessed december 25, 2021; 11:57 hrs cst) 10. israel to offer fourth covid-19 booster dose. almonitor. december 21, 2021. https://www.almonitor.com/originals/2021/12/israel-offer-fourth-covid19-booster-dose (accessed december 25, 2021; 12:33 hrs cst) https://journals.lww.com/jaapa/abstract/2020/07000/the_effect_of_the_covid_19_pandemic_on_healthcare.9.aspx https://onlinelibrary.wiley.com/doi/10.1111/inr.12598 https://onlinelibrary.wiley.com/doi/10.1111/inr.12598 https://www.tandfonline.com/doi/full/10.1080/13561820.2020.1792425 https://www.tandfonline.com/doi/full/10.1080/13561820.2020.1792425 https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html https://www.federalregister.gov/documents/2021/11/05/2021-23831/medicare-and-medicaid-programs-omnibus-covid-19-health-care-staff-vaccination https://www.federalregister.gov/documents/2021/11/05/2021-23831/medicare-and-medicaid-programs-omnibus-covid-19-health-care-staff-vaccination https://www.federalregister.gov/documents/2021/11/05/2021-23831/medicare-and-medicaid-programs-omnibus-covid-19-health-care-staff-vaccination https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-new-long-acting-monoclonal-antibodies-pre-exposure https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-new-long-acting-monoclonal-antibodies-pre-exposure https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-new-long-acting-monoclonal-antibodies-pre-exposure https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-new-long-acting-monoclonal-antibodies-pre-exposure https://www.fda.gov/media/154701/download https://www.al-monitor.com/originals/2021/12/israel-offer-fourth-covid-19-booster-dose https://www.al-monitor.com/originals/2021/12/israel-offer-fourth-covid-19-booster-dose https://www.al-monitor.com/originals/2021/12/israel-offer-fourth-covid-19-booster-dose 2022, vol. 2 (s1) 4-6 https://doi.org/10.47488/dhrp.v2is1.41 http://dhrproceedings.org 4 © dhr health institute for research and development commentary challenges and opportunities in conducting translational and clinical research in academic institutions and universities sohail rao, md, ma, dphil1, 2 1executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas 78539 and president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0001-5027-9992 2 correspondence should be addressed to: sohail rao, md, ma, dphil., dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. tel: (956) 362-2387. e-mail: s.rao@dhr-rgv.com received 03/01/2022 accepted for publication 03/01/2022 published 03/01/2022 keywords: clinical research; translational research; independent research centers the global clinical trials market size was estimated at usd 44.3 billion in 2020 and is expected to expand at a compound annual growth rate of 5.7% from 2021 to 2028. however, the market growth was hindered in 2020 due to the covid-19 pandemic. nevertheless, the future seems promising for the market owing to factors such as globalization of clinical trials, rapid technological evolution, and augmenting demand for clinical research organizations to conduct research activities. the increasing prevalence of chronic disease and the growing demand for clinical trials in developing countries are also fueling this market’s growth. the market is also driven by a rising number of biologics, the need for personalized medicines and orphan drugs, and demand for advanced technologies. cooperation among a diverse group of stakeholders— including research sponsors (industry, academia, government, nonprofit organizations, clinical research organizations, and patient advocates), clinical investigators, patients, payers, physicians, and regulators—is necessary in conducting a clinical trial today. each stakeholder offers a different set of tools to support the essential components of a clinical trial. these resources form the infrastructure that currently supports clinical research in the united states. time, money, personnel, materials (e.g., medical supplies), support systems (informatics as well as manpower), and a clear plan for completing the necessary steps in a trial are all part of the clinical research infrastructure. most clinical trials are conducted in a “one-off” manner in which the necessary components of a trial (usually a single coordinating center and multiple research sites) are brought together for a discrete period of time and disbanded once the trial is completed. it is interesting to note that fewer than half of all the medical treatments delivered today are supported by evidence and yet the united states lacks a clear prioritization of the gaps in medical evidence and allocation of clinical research resources to fill these evidence gaps efficiently and effectively (1). the federal government, industry, academic institutions, patient advocacy organizations, voluntary health organizations, and payers each have incentives to develop research questions that suit their unique interests. the value of a particular research effort is judged by stakeholders according to their own cost–benefit calculation. reflecting the diversity of stakeholder value judgments, and in the absence of a broad national agenda, clinical trials are conducted in a “one-off,” narrowly focused fashion. because clinical trials are necessary to obtain regulatory approval in the united states, they are a high priority to companies. therefore, prioritization of clinical research questions by companies seeking regulatory approval is distinctly different from the priorities of society in general, which may prioritize the comparison of two commonly used therapies. this divergence between the priorities of society https://orcid.org/0000-0001-5027-9992 mailto:s.rao@dhr-rgv.com dhrp, 2022, vol. 2 (s1) 4-6 clinical research in academic institutions http://dhrproceedings.org 5 © dhr health institute for research and development and industry is notable as the nation discusses how to address the current gaps in clinical research and medical decision making. significant time, energy, and money are spent on bringing the disparate resources for each trial together. it is therefore reasonable to argue that efficiencies could be gained by streamlining the clinical trials infrastructure so that those investigating new research questions could quickly draw on resources already in place instead of reinventing the wheel for each trial. the process for obtaining us food and drug administration approval for a drug and/or a biological agent is extremely protracted and cumbrous. on an average, it takes 10-17 years for a drug to be approved for use in humans costing in most instances millions of dollars to the biopharmaceutical industry (figure 1). therefore, it is imperative that entities involved in clinical research focus on managing the time to recruitment of the first patient in each trial an outcome that can only be accomplished by having a streamlined process (table 1). they must also ensure that the data is of the highest quality and available to the sponsors in a timely manner and that the research subjects screened and/or accrued in each clinical trial must meet the inclusion and exclusion criteria outlined in the protocol. figure 1: time to completion of various phases of clinical trials and the number of biological molecules tested to yield one (1) fda-approved drug in the past, clinical research was performed primarily at major academic centers and universities. however, today most clinical research is performed in independent research centers and private clinics throughout the country. many of the changes were brought on by rising costs in health care and the growing bureaucracies in academic institutions that have made initiating clinical research an onerous task in these entities. the practice of evidence-based medicine is at the core of providing quality and innovative clinical care and to accomplish this objective, it is quintessential for any organization involved in patient care to conduct translational and clinical research. therefore, if academic institutions and universities who are involved in clinical care, are serious about regaining their share of translational and clinical research, they must undergo a transformational change and adopt a more streamlined process for initiating trials in their facilities and work towards eliminating the unnecessary burden of administrative bureaucracy that has resulted in this outcome. table 1: critical components of a streamlined review, approval, and implementation process for a successful clinical research trial regulatory • succinct policies & guidelines • patient-centered institution review board (irb) operations • master affiliation agreements with sponsors • budgets and contracts • confidentiality/nondisclosure agreements technology • feasibility studies • electronic data capture application • user-friendly electronic medical record • investigator-friendly electronic irb submission software personnel • physician investigator • advanced practice nurse (if required) • experience clinical research coordinator • support staff (medical assistants, phlebotomist, data managers, etc) • research information technologists infrastructure • adequate space, equipment, and supplies it is our recommendation that for academic institutions and universities to be successful in conducting translational and clinical research, they must seriously consider establishing an independent nonprofit research institute that is tasked with the responsibility of managing the entire process and have all the critical components under one roof that are outlined in dhrp, 2022, vol. 2 (s1) 4-6 clinical research in academic institutions http://dhrproceedings.org 6 © dhr health institute for research and development table 1. this would be in the best interest of the academic institutions and the universities as it would isolate the inherent risk and liability associated with the conduct of clinical trials. lastly, the person assigned to lead this process must be a visionary who is a seasoned clinical investigator and research administrator with documented experience and expertise in establishing and managing such entities. diclosures sr declares no conflicts of interest. funding the project is funded by a seed grant from the dhr health institute for research & development references 1. institute of medicine (us) roundtable on evidencebased medicine. the healthcare imperative: lowering costs and improving outcomes: workshop series summary. yong pl, saunders rs, olsen l, editors. washington (dc): national academies press (us); 2010. pmid: 21595114. volume 2 no. s3: second quarter editorial https://doi.org/10.47488/dhrp.v2is3.67 dhr proceedings ǀ http://dhrproceedings.org 2022, vol. 2 no. s3 1-9 1 editorial paxlovid rebound: proposed strategy to prevent reinfection following treatment of covid-19 positive nonhospitalized patients sohail rao, md, ma, dphil,1 and manish singh, md, facs, fasmbs2 1executive vice president for research & leadership development, dhr health, 5501 s. mccoll road, edinburg, texas 78539, and founding president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0001-5027-9992 2dhr health bariatric and metabolic institute and chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas 78539 and dhr health bariatric & metabolic institute, 5500 raphael drive, edinburg, tx 79539 orcid: https://orcid.org/0000-0003-4146-3282 correspondence should be addressed to: sohail rao, md, ma, dphil., dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. e-mail: s.rao@dhr-rgv.com. keywords: covid-19; sars-cov-2; ba.5; ba.5; omicron; paxlovid; malnupiravir; bebtelovimab; evusheldtm; malnupiravir; remdesivir; cdc: centers for disease control and prevention; fda: u.s. food and drug administration; who: world health organization b.1.1.529, the new lineage of sars-cov-2 variant was first detected in botswana on november 11, 2021, and in south africa on november 14, 2021. this new variant had many mutations in portions of the genome that increased its infectivity and transmissibility; conferred resistance to certain therapeutics; and reduced neutralization by monoclonal antibodies (1,2). given these observations, on november 26, 2021, who classified b.1.1.529 as a variant of concern and named it omicron (3). on november 30, 2021, the u.s. sarscov-2 interagency group (sig), which includes the centers for disease control and prevention (cdc), the national institutes of health, the food and drug administration, the biomedical advanced research and development authority, and the departments of defense, agriculture, and health and human services, classified the omicron variant as a variant of concern. since its first identification, a total of six omicron variants have been identified (table 1). many of the earlier variants were responsive to available experimental treatment including monoclonal antibodies such as sotrovimab (4). however, both ba.4 and ba.5 were found less responsive to some for the existing therapies. ba.4 was first identified in the us in april 2022 but was soon replaced by ba.5 as the dominant variant that is currently responsible for majority of covid-19 cases https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0003-4146-3282 mailto:s.rao@dhr-rgv.com rao, et al paxlovid rebound https://doi.org/10.47488/dhrp.v2is3.67 dhr proceedings ǀ http://dhrproceedings.org 2022, vol. 2 no. s3 1-9 2 (figure 1). ba.5 is probably the most transmissible variant of omicron and has certain characteristic that are unique to this mutant: • infects those who have had previous natural infection from earlier variants of sars-cov2 • escapes immunity due to covid-19 vaccination • poor neutralization by previously existing experimental monoclonal antibodies given these characteristics, fda revised its recommendation for the treatment of hospitalized and nonhospitalized patients infected with the ba.4 and ba.5 variants of omicron (table 2). paxlovid, an oral antiviral medication, was recommended as the preferred option for the treatment of nonhospitalized mild-to-moderate sars-cov-2 infection in individuals 12 and older at high risk of progression to severe disease (figure 3 and 4). additionally, bebtelovimab, a monoclonal antibody for the treatment of acute covid-19 in the outpatient setting, is equally effective but in extremely short supply and it is recommended that it should be reserved for individuals with a contraindication to preferred therapies. more importantly, availability of bebtelovimab after the third week of august is uncertain and as of august 01, 2022, patients would be required to pay to get treated with this monoclonal antibody. it is noteworthy that under an irb-approved protocol, we at the dhr health institute for research & development have treated to date over 400 high risk covid-19 positive patients with bebtelovimab with very satisfactory outcomes. while paxlovid is the recommended drug of choice for treating mild-moderate nonhospitalized patients, it does have certain limitations (5). despite its therapeutic effectiveness, paxlovid is contraindicated in the following conditions which limits its utility (6): • patients requiring hospitalization • for pre-exposure or post-exposure prophylaxis • for use beyond recommended 5 consecutive days • patients with clinically significant hypersensitivity reactions (e.g., toxic epidermal necrolysis and stevens-johnson syndrome) • patients on drugs requiring cyp3a for clearance • patients on drugs that are potent induces of cyp3a of equal concern is the recent observation of high incidence of re-infection following treatment with paxlovid (8). in a recent study involving 13,600 patients, it was reported that 7-day and 30-day covid-19 rebound rates after paxlovid treatment were 3.53% and 5.40% for sars-cov-2 infection, 2.31% and 5.87% for covid-19 symptoms, and 0.44% and 0.77% for hospitalizations (8). while it requires further validation, there is however some recent evidence that the re-infection rate is probably as high as 20-40% in patients treated with paxlovid (9). rebound of sars-cov-2 infection in high profile cases following the recommended 5-day oral treatment with paxlovid has further highlighted this concern (10 11). in one particular case, the patient resorted to taking a second course of paxlovid after experiencing covid-19 rebound which, at the present time is not recommended by the fda (10). rebound of covid-19 symptoms following the use of paxlovid treatment is likely due to insufficient drug exposure: not enough of the drug was getting to infected cells to stop all viral replication. this could be due to the drug being rao, et al paxlovid rebound https://doi.org/10.47488/dhrp.v2is3.67 dhr proceedings ǀ http://dhrproceedings.org 2022, vol. 2 no. s3 1-9 3 metabolized more quickly in some individuals or that the drug needs to be delivered over a longer treatment duration. it is therefore our recommendation that has also been voiced by others (12) that both pfizer (the manufactures of paxlovid) and fda review the data and either increase the duration of treatment (from 5 days to 7-10 days) and/or allow the use of another 3–5-day course of paxlovid for patients suffering from rebound. alternatively combined use of bebtelovimab and paxlovid could be considered for contemporaneous reduction of both the circulating viral load and prevention of viral replication in infected cells. funding: the project was funded by a seed grant from the dhr health institute for research & development and the dhr health conflict of interest: the authors have reported no conflict of interest references: 1. chen j, wei gw. omicron ba.2 (b.1.1.529.2): high potential to becoming the next dominating variant. res sq [preprint]. 2022 feb 23:rs.3.rs-1362445. doi: 10.21203/rs.3.rs-1362445/v1. update in: j phys chem lett. 2022 apr 25:3840-3849. pmid: 35233567; pmcid: pmc8887081. 2. chen j, wang r, gilby nb, wei gw. omicron variant (b.1.1.529): infectivity, vaccine breakthrough, and antibody resistance. j chem inf model. 2022 jan 24;62(2):412-422. doi: 10.1021/acs.jcim.1c01451. epub 2022 jan 6. pmid: 34989238; pmcid: pmc8751645. 3. classification of omicron (b.1.1.529): sars-cov-2 variant of concern. who. november 26, 2021. https://www.who.int/news/item/26-11-2021classification-of-omicron-(b.1.1.529)-sarscov-2-variant-of-concern 4. martin-blondel g, marcelin ag, soulié c, et.al. sotrovimab to prevent severe covid19 in high-risk patients infected with omicron ba.2. j infect. 2022 jul 5:s01634453(22)00406-6. doi: 10.1016/j.jinf.2022.06.033. epub ahead of print. pmid: 35803386; pmcid: pmc9254651. 5. hammond, j., leister-tebbe, h., gardner, a, et.al. oral nirmatrelvir for high-risk, nonhospitalized adults with covid19.hammond, ph.d., april 14, 2022 n engl j med 2022; 386:1397-1408 doi: 10.1056/nejmoa2118542 6. coronavirus (covid-19) update: fda authorizes first oral antiviral for treatment of covid-19. fda. december 22, 2021. https://www.fda.gov/news-events/pressannouncements/coronavirus-covid-19update-fda-authorizes-first-oral-antiviraltreatment-covid-19 7. covid-19 rebound after paxlovid treatment. cdc. may 24, 2022, https://emergency.cdc.gov/han/2022/han004 67.asp 8. wang l., berger na., davis pb., et.al. covid19 rebound after paxlovid and molnupiravir during january-june 2022, medrxiv 2022. 08.21.22276724; https://www.who.int/news/item/26-11-2021-classification-of-omicron-(b.1.1.529)-sars-cov-2-variant-of-concern https://www.who.int/news/item/26-11-2021-classification-of-omicron-(b.1.1.529)-sars-cov-2-variant-of-concern https://www.who.int/news/item/26-11-2021-classification-of-omicron-(b.1.1.529)-sars-cov-2-variant-of-concern https://www.nejm.org/doi/full/10.1056/nejmoa2118542 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-oral-antiviral-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-oral-antiviral-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-oral-antiviral-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-oral-antiviral-treatment-covid-19 https://emergency.cdc.gov/han/2022/han00467.asp https://emergency.cdc.gov/han/2022/han00467.asp rao, et al paxlovid rebound https://doi.org/10.47488/dhrp.v2is3.67 dhr proceedings ǀ http://dhrproceedings.org 2022, vol. 2 no. s3 1-9 4 doi: https://doi.org/10.1101/2022.06.21.222 76724 9. farrell p. covid reinfection rate with treatment biden is taking is more than 40% and not 2% as marketed: paxlovid is thought to suppress immune response meaning body can’t fight off new infection. daily mail. july 30, 2022. https://www.dailymail.co.uk/news/article11065467/covid-reinfection-rate-treatmentbiden-taking-40-not-2-marketed.html 10. lee by. dr. fauci takes 2nd course of paxlovid after suffering covid-19 rebound. forbes. june 30, 2022. https://www.forbes.com/sites/brucelee/2022/ 06/30/dr-fauci-takes-2nd-course-ofpaxlovid-after-suffering-covid-19rebound/?sh=4964bf0315d6 11. judd d and cole d. biden still testing positive after rebound covid-19 case but ‘continues to feel well,’ white house says. cnn. july 31, 2022. https://www.cnn.com/2022/07/31/politics/jo e-biden-covid-positive-day-two/index.html 12. mlynark n. covid-19 rebound after taking paxlovid likely due to insufficient drug exposure. ucsd. june 21, 2022. https://health.ucsd.edu/news/releases/pages/ 2022-06-21-covid-19-rebound-after-takingpaxlovid-likely-due-to-insufficient-drugexposure.aspx https://doi.org/10.1101/2022.06.21.22276724 https://doi.org/10.1101/2022.06.21.22276724 https://www.dailymail.co.uk/news/article-11065467/covid-reinfection-rate-treatment-biden-taking-40-not-2-marketed.html https://www.dailymail.co.uk/news/article-11065467/covid-reinfection-rate-treatment-biden-taking-40-not-2-marketed.html https://www.dailymail.co.uk/news/article-11065467/covid-reinfection-rate-treatment-biden-taking-40-not-2-marketed.html https://www.forbes.com/sites/brucelee/2022/06/30/dr-fauci-takes-2nd-course-of-paxlovid-after-suffering-covid-19-rebound/?sh=4964bf0315d6 https://www.forbes.com/sites/brucelee/2022/06/30/dr-fauci-takes-2nd-course-of-paxlovid-after-suffering-covid-19-rebound/?sh=4964bf0315d6 https://www.forbes.com/sites/brucelee/2022/06/30/dr-fauci-takes-2nd-course-of-paxlovid-after-suffering-covid-19-rebound/?sh=4964bf0315d6 https://www.forbes.com/sites/brucelee/2022/06/30/dr-fauci-takes-2nd-course-of-paxlovid-after-suffering-covid-19-rebound/?sh=4964bf0315d6 https://www.cnn.com/2022/07/31/politics/joe-biden-covid-positive-day-two/index.html https://www.cnn.com/2022/07/31/politics/joe-biden-covid-positive-day-two/index.html https://health.ucsd.edu/news/releases/pages/2022-06-21-covid-19-rebound-after-taking-paxlovid-likely-due-to-insufficient-drug-exposure.aspx https://health.ucsd.edu/news/releases/pages/2022-06-21-covid-19-rebound-after-taking-paxlovid-likely-due-to-insufficient-drug-exposure.aspx https://health.ucsd.edu/news/releases/pages/2022-06-21-covid-19-rebound-after-taking-paxlovid-likely-due-to-insufficient-drug-exposure.aspx https://health.ucsd.edu/news/releases/pages/2022-06-21-covid-19-rebound-after-taking-paxlovid-likely-due-to-insufficient-drug-exposure.aspx rao, et al paxlovid rebound https://doi.org/10.47488/dhrp.v2is3.67 dhr proceedings ǀ http://dhrproceedings.org 2022, vol. 2 no. s3 1-9 5 table 1: various variants of omicron since its first identification in november 11, 2022 and the frequency of patients infected in the united states as of july 23, 2022 omicron lineage percentage of patients infected ba.1.1 0.0% ba.1.1.529 0.0% ba.2 0.3% ba.2.12.1 5.0% ba.4 12.9% ba.5 81.9% rao, et al paxlovid rebound https://doi.org/10.47488/dhrp.v2is3.67 dhr proceedings ǀ http://dhrproceedings.org 2022, vol. 2 no. s3 1-9 6 figure 1: timeline of various omicron lineages causing sars-cov-2 infection in the united states (adopted from cdc website): https://covid.cdc.gov/covid-data-tracker/#variant-proportions) https://covid.cdc.gov/covid-data-tracker/#variant-proportions rao, et al paxlovid rebound https://doi.org/10.47488/dhrp.v2is3.67 dhr proceedings ǀ http://dhrproceedings.org 2022, vol. 2 no. s3 1-9 7 table 2: hospitalized and outpatient treatment of patients infected with the ba.4 and ba.5 variants of omicron experimental drug inpatient vs. outpatient severity of disease reference bebtelovimab monoclonal antibody outpatient mild to moderate https://www.fda.gov/media/156152/download remdesivir (velkury) outpatient mild to moderate https://www.fda.gov/news-events/pressannouncements/fda-takes-actions-expand-usetreatment-outpatients-mild-moderate-covid-19 remdesivir + baricitinib (olumiant) inpatient severe https://www.fda.gov/news-events/pressannouncements/coronavirus-covid-19-updatefda-authorizes-drug-combination-treatmentcovid-19 ritonavir-boosted nirmatrelvir (paxlovid) outpatient mild-moderate https://www.paxlovid.com/?source=bing&hb x_pk=s_paxlovid&skwid=43700068281647 229&gclid=c926586053d315737f663a86b321 0308&gclsrc=3p.ds malnupiravir (lagevrio) outpatient mild-moderate https://www.nejm.org/doi/full/10.1056/nejm oa2116044 evusheldtm (tixagevimab and cilgavimab) outpatient pre-exposure prophylaxis in high-risk patients https://www.evusheld.com/en/patient https://www.fda.gov/drugs/drug-safety-andavailability/fda-authorizes-revisionsevusheld-dosing https://www.fda.gov/media/156152/download https://www.fda.gov/news-events/press-announcements/fda-takes-actions-expand-use-treatment-outpatients-mild-moderate-covid-19 https://www.fda.gov/news-events/press-announcements/fda-takes-actions-expand-use-treatment-outpatients-mild-moderate-covid-19 https://www.fda.gov/news-events/press-announcements/fda-takes-actions-expand-use-treatment-outpatients-mild-moderate-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-drug-combination-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-drug-combination-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-drug-combination-treatment-covid-19 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-drug-combination-treatment-covid-19 https://www.paxlovid.com/?source=bing&hbx_pk=s_paxlovid&skwid=43700068281647229&gclid=c926586053d315737f663a86b3210308&gclsrc=3p.ds https://www.paxlovid.com/?source=bing&hbx_pk=s_paxlovid&skwid=43700068281647229&gclid=c926586053d315737f663a86b3210308&gclsrc=3p.ds https://www.paxlovid.com/?source=bing&hbx_pk=s_paxlovid&skwid=43700068281647229&gclid=c926586053d315737f663a86b3210308&gclsrc=3p.ds https://www.paxlovid.com/?source=bing&hbx_pk=s_paxlovid&skwid=43700068281647229&gclid=c926586053d315737f663a86b3210308&gclsrc=3p.ds https://www.nejm.org/doi/full/10.1056/nejmoa2116044 https://www.nejm.org/doi/full/10.1056/nejmoa2116044 https://www.evusheld.com/en/patient https://www.fda.gov/drugs/drug-safety-and-availability/fda-authorizes-revisions-evusheld-dosing https://www.fda.gov/drugs/drug-safety-and-availability/fda-authorizes-revisions-evusheld-dosing https://www.fda.gov/drugs/drug-safety-and-availability/fda-authorizes-revisions-evusheld-dosing rao, et al paxlovid rebound https://doi.org/10.47488/dhrp.v2is3.67 dhr proceedings ǀ http://dhrproceedings.org 2022, vol. 2 no. s3 1-9 8 figure 2: covid-19 outpatient therapeutics clinical decision aid for ages 12+ years adult or pediatric patient (ages 12 and older weighing at least 40 kg) with mild to moderate covid-19 and at high risk for progression to severe disease rao, et al paxlovid rebound https://doi.org/10.47488/dhrp.v2is3.67 dhr proceedings ǀ http://dhrproceedings.org 2022, vol. 2 no. s3 1-9 9 figure 3: covid-19 outpatient therapeutics 18 july 2022 clinical decision aid for ages 28 days to less than 12 years pediatric patient (28 days of age to less than 12 years, weighing at least 3 kg to less than 40 kg) with mild to moderate covid-19 and at high risk for progression to severe disease special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.47 dhr proceedings ǀ http://dhrproceedings.org 11 2022, vol. 2 no. s2 11-14 commentary changes in adolescents’ mental health after covid-19 stefany estrada1,2, itzel loreto1,3, maddox mina1,4, isaac santoyo1,5, amerie varela1,6 1 2nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2 port isabel high school, port isabel, tx 3 zapata high school, zapata tx 4 idea pharr college preparatory, pharr, tx 5 mcallen high school, mcallen, tx 6 weslaco high school, weslaco, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 06/17/2022 accepted for publication 07/14/2022 published 07/14/2022 keywords: covid-19, social isolation, depression, anxiety, mental health, loneliness, pandemic, adolescents introduction in february 2020, the united states was shocked with a virus that abruptly changed citizens’ lives, particularly those of adolescents. initially, students were let out for an extended spring break, only to find out that they would not be returning to in-person instruction until further notice. covid-19, also known as the coronavirus disease, was first discovered in wuhan, china in december of 2019. research has shown that specific viruses, such as beta coronaviruses and alpha coronaviruses, are known to have the main host be a bat or other zoonotic organism (1). an individual who contracts this disease may experience symptoms such as fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea (2). sars-cov-2 is transmitted by direct or close contact with aerosolized particles of the virus thus causing a respiratory infection. to regulate transmission, society was put under a worldwide quarantine. citizens were expected to stay in their houses, universal mask mandates were imposed, and copious amounts of hand sanitizer and disinfecting wipes were utilized like never before. due to the social isolation brought along with this global pandemic, society has been presented with a staggering 60.8% increase in anxiety, a 54.1% increase in the feeling of loneliness, and a 59.8% increase in depression (3). the impact on society’s mental health was unparalleled. social isolation social interaction is essential in a person's life, therefore government imposed lockdowns may cause isolation and loneliness. an article from 2020 stated that social isolation and loneliness increased the risk of depression, and possibly anxiety up to 9 years later. they also found that duration of loneliness was more strongly correlated with mental health symptoms than intensity of loneliness (4). results from this study show that potential issues with depression and anxiety can follow the events of isolation. in the context of estrada, et al adolescents mental health after covid-19 https://doi.org/10.47488/dhrp.v2is2.47 dhr proceedings ǀ http://dhrproceedings.org 12 2022, vol. 2 no. s2 11-14 covid-19, we know that some students were forced to stay home to take care of their younger siblings, forced to go to work because their parents were unemployed due to covid-19, or weren’t able to communicate with people because they didn’t have the financial and technological resources needed to communicate with others. previous literature has also found that loneliness has been a factor for sensory loss, connective tissue, auto-immune disorders, cardiovascular disorders and obesity. if loneliness continues, it may decrease physical activity leading to an increased risk of frailty and fractures (5). the study shows that not only does social isolation affect mental health but physical as well. as researchers, there should be work to mitigate the effects of isolation in the youth population. adolescents are likely to experience depression and anxiety during and after quarantine, so clinical services should offer support and interventions as well as be prepared for the increase of mental health problems. depression depression is a mental condition characterized by chronic sorrow and loss of interest. it affects how you feel, think, and behave and can lead to a variety of mental and physical difficulties. it is also known as major depressive disorder and is defined as “a sad mood lasts for a long time and begins to interfere with normal, everyday functions.” (6) in a study done on chinese adolescents in shanghai, a survey was distributed to 4,342 primary and secondary school students that included questions about their physiological distress, life satisfaction and perceived view on at-home quarantine. the results showed that depression was the second most prominent disease with (19.7%) of the participants developing new symptoms (7). concerning, amongst the participants, each developed new issues, after being sent home for quarantine. under-recognized and untreated depression and anxiety symptoms have deleterious effects on physical functioning and social interaction which would lead to an increase in fatigue (8). in this study, depression also increased across participants due to the lack of student interaction within one another. as an additional burden, covid-19 restrictions kept students from attending practice, going to the gym or doing any sort of physical activity, which are important activities to combat signs of depression. these findings are not unique to adolescents suffering in asia but also affecting children in north america. similarly, in a study conducted on adolescents in the united states, an online questionnaire was used to gather information regarding students’ mental health post-lockdown. the results indicated that an alarming 39% of the 1,948 participants developed symptoms of depression after the government-mandated lockdown (9). common causes amongst students were fear of getting infected, being unaware of the effects of covid-19, facing the rapid increase of cases, contemplating the detrimental outcomes including death, and having to adjust to a new environment of learning. with problems such as having to worry about not having the internet available, a less peaceful atmosphere where students can’t focus, especially if siblings participate in online classes, and not having the peace of mind that they are able to discuss their problems or questions to the professor easily, there’s no doubt students have developed some mental blockade from its notable effects. similarly, both continents have both grown equally in depression cases, living in similar conditions (7,9). anxiety anxiety is the excessive, constant fear and intense worry about everyday situations. it is an emotion characterized by their feelings of tension and certain thoughts (10). people with anxiety disorders often have recurring thoughts or concerns that bother them. they may avoid certain situations out of fear, creating general anxiety. covid-19 has caused adolescents to worry about getting sick during the pandemic, and constantly worrying about the future. anxiety may also have physical symptoms such as sweating, trembling, dizziness or a fast heartbeat (10). many young adolescents have suffered from anxiety throughout covid-19, specifically from being isolated throughout the pandemic and not participating in any social interactions (11). young children were left alone by working parents, unsupervised at home, which had an effect on many children creating separation anxiety. bottling up many feelings and not being able to talk to someone was also a cause which created excessive feelings in many situations. many families have also lost close relatives due to covid-19 and did not have any social support, which caused them to be irritable and angry. the pandemic made it hard for many, specifically adolescents who were already struggling with mental health, bringing them a sense of loneliness and stress after being isolated in their own homes for a long estrada, et al adolescents mental health after covid-19 https://doi.org/10.47488/dhrp.v2is2.47 dhr proceedings ǀ http://dhrproceedings.org 13 2022, vol. 2 no. s2 11-14 period of time and then having to return to their original lives. although being isolated caused many to encounter anxiety symptoms, having to return to the community, their normal routines and hide the setbacks in their academic and professional work has been difficult for many people (12). this can increase rates of elevated anxiety and depression symptoms in young adolescents, which can lead to frustration and helplessness. it is presumed that children might resist going to school after the lockdown is over and may face difficulty in establishing rapport with their mentors after the schools reopen. consequently, the constraint of movement imposed on them can have a long term negative effect on their overall psychological wellbeing (13). two studies have reported rates of anxiety ranging from 18.9% to 37.4% in young people during the pandemic (14). because of school closure, it has influenced the behavior of many adolescents. many school activities helped these teens with their physical and mental health. conclusion the worldwide coronavirus pandemic has presented society with many aspects, a large majority of them negatively impacting one's mental health. to name a few of these effects, social isolation, leading to loneliness and mental health issues, such as depression and anxiety. if one already had any of these issues, they would escalate to an unthought of extent and would lead to an increased rate of suicides. the result of this pandemic has caused a mental health impact that is just staggering. these emotional reactions were outcomes from being secluded from the world throughout covid-19. this pandemic has had such a great impact on everyone, especially on adolescents affecting their mental health immensely. we can help our adolescents by taking them to a therapist where they can get help, where they can talk about their troubles or just somewhere we know they can get better. we are still trying to recover slowly but surely. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected and region one esc paths references 1. hu, b., guo, h., zhou, p., & shi, z. l. (2021). characteristics of sars-cov-2 and covid-19. nature reviews. microbiology, 19(3), 141–154. https://doi.org/10.1038/s41579-020-00459-7 2. centers for disease control and prevention. (2022, march 22). symptoms of covid-19. centers for disease control and prevention. https://www.cdc.gov/coronavirus/2019ncov/symptoms-testing/symptoms.html 3. lee, j., solomon, m., stead, t., kwon, b., & ganti, l. (2021). impact of covid-19 on the mental health of us college students. bmc psychology, 9(1), 95. https://doi.org/10.1186/s40359-021-00598-3 4. loades, m. e., chatburn, e., higsonsweeney, n., reynolds, s., shafran, r., brigden, a., linney, c., mcmanus, m. n., borwick, c., & crawley, e. (2020). rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of covid-19. journal of the american academy of child and adolescent psychiatry, 59(11), 1218–1239.e3. https://doi.org/10.1016/j.jaac.2020.05.009 5. mushtaq, r., shoib, s., shah, t., & mushtaq, s. (2014). relationship between loneliness, psychiatric disorders and physical health? a review on the psychological aspects of loneliness. journal of clinical and diagnostic research: jcdr, 8(9), we01–we4. https://doi.org/10.7860/jcdr/2014/10077.4 828 6. cdc. (2018, april 23). mental health conditions: depression and anxiety. centers for disease control and prevention. estrada, et al adolescents mental health after covid-19 https://doi.org/10.47488/dhrp.v2is2.47 dhr proceedings ǀ http://dhrproceedings.org 14 2022, vol. 2 no. s2 11-14 https://www.cdc.gov/tobacco/campaign/tips/ diseases/depression-anxiety.html 7. tang, s., xiang, m., cheung, t., & xiang, y. t. (2021). mental health and its correlates among children and adolescents during covid-19 school closure: the importance of parent-child discussion. journal of affective disorders, 279, 353–360. https://doi.org/10.1016/j.jad.2020.10.016 8. yohannes, a. m., & alexopoulos, g. s. (2014). depression and anxiety in patients with copd. european respiratory review: an official journal of the european respiratory society, 23(133), 345–349. https://doi.org/10.1183/09059180.00007813 9. khubchandani, j., sharma, s., webb, f. j., wiblishauser, m. j., & bowman, s. l. (2021). post-lockdown depression and anxiety in the usa during the covid-19 pandemic. journal of public health (oxford, england), 43(2), 246–253. https://doi.org/10.1093/pubmed/fdaa250 10. american psychological association (2022, june 15). anxiety https://www.apa.org/topics/anxiety#:~:text= anxiety%20is%20an%20emotion%20chara cterized,changes%20like%20increased%20b lood%20pressure. 11. marques de miranda, d., da silva athanasio, b., sena oliveira, a. c., & simoes-e-silva, a. c. (2020). how is covid-19 pandemic impacting mental health of children and adolescents. international journal of disaster risk reduction: ijdrr, 51, 101845. https://doi.org/10.1016/j.ijdrr.2020.101845 12. tang, s., xiang, m., cheung, t., & xiang, y. t. (2021). mental health and its correlates among children and adolescents during covid-19 school closure: the importance of parent-child discussion. journal of affective disorders, 279, 353–360. https://doi.org/10.1016/j.jad.2020.10.016 13. singh, s., roy, d., sinha, k., parveen, s., sharma, g., & joshi, g. (2020). impact of covid-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. psychiatry research, 293, 113429. https://doi.org/10.1016/j.psychres.2020.1134 29 14. nearchou, finiki et al. “exploring the impact of covid-19 on mental health outcomes in children and adolescents: a systematic review.” international journal of environmental research and public health vol. 17,22 8479. 16 nov. 2020, https://doi:10.3390/ijerph17228479. https://doi:10.3390/ijerph17228479 2021, vol. 1 (s5) 4-6 https://doi.org/10.47488/dhrp.v1is5.30 http://dhrproceedings.org 4 © dhr health institute for research and development commentary don’t abandon your mask (and other public health measures) quite yet r. armour forse md, phd, frcs(c), facs,1 anthony o. obinna rn, bsmt, mbahca, cic 2 and manish singh md, facs 3 1 chief academic officer and designated institutional official dhr health, 5501 s. mccoll road, edinburg, texas, 78539 2 director of infection prevention and control, dhr health, 5501 s. mccoll road, edinburg, texas, 78539 3 chief executive officer, dhr health, 5501 s. mccoll road, edinburg tx 78539 and dhr health bariatric and metabolic institute, 500 raphael drive, edinburg, tx 78539 orcid: manish singh: https://orcid.org/0000-0003-4146-3282 received 10/25/2021 accepted for publication 10/27/2021 published 10/28/2021 keywords: covid-19; public health measures the impact of covid-19 vaccinations continues to make a significant difference with the pandemic. recent cdc guidelines provide advice on being able to do more activities without the mask if you are fully covid-19 vaccinated. but before you put that mask away there are a few things to remember. when the pandemic broke out there were no vaccines and no medications to combat the covid-19 virus. four key public health measures were instituted. one, if you were infected, you needed to quarantine, two wear a mask, three keep your social distance and four, always perform proper hand hygiene. these public health measures really worked and had a synergistic impact. in fact, in our hospital, dhr health, the only outbreaks in the hospital occurred when someone infected and sick with covid-19 came to work and when health care workers (hcw) congregated together such as for a coffee or meal at which time they did not wear a mask and were not social distancing. otherwise, the public health measures were effective in controlling the spread of the covid-19 (dhr health infection prevention and control data). it is important to understand that vaccination does not prevent you from becoming infected with covid-19; it prevents you from becoming very ill or dying from covid-19. even then the vaccination effect is not absolute. vaccinated people have become very ill, have been hospitalized, and yes, vaccinated people have died from covid-19; usually due to having comorbidities such as obesity and diabetes or they are immunocompromised. this is why the cdc has continued to recommend that health care workers in the hospital continue to wear masks, social distance and observe good hand hygiene no matter what their vaccination status (cdc ref). what has been very educational is the effect of these public health measures on other infectious diseases. the best example was the influenza viruses. over the past year of 2020, influenza became almost extinct as compared to all the years of influenza reporting. adult infections were dramatically decreased, not only in north america but globally. the who organization data for all continents showed a similar effect (who). not only were influenza infections decreased but influenza deaths as well. this effect was also evident in children where there was a significant, 65.7%, decrease in respiratory infections. associated with this decrease in infections was a 60% decrease in outpatient visits, and a significant decrease in hospitalization and hospital length of stay (los). even more impressive is that the cdc reported only one pediatric flu related death in the 2020-2021 flu season versus 196 in the 2019-2020 season. this decrease in pediatric respiratory infections represented cases of adenovirus, influenza a, influenza b, and respiratory syncytial virus (rsv). these data help to illustrate that the public health measures are effective in controlling infectious diseases, particularly those for which there is no medical therapy nor vaccine.these public measures have an interesting history and by no means are new…they are historic. the important concept of quarantine has been around https://orcid.org/0000-0003-4146-3282 dhrp, 2021, vol. 1 (s5) 4-6 protective effect of public health measures http://dhrproceedings.org 5 © dhr health institute for research and development for a long time. the term comes from “quaranta” meaning 40. started in venice, italy to control the plague, the number 40 was the chosen number of days of isolation. the data behind the 40 days is quite variable ranging from being derived from hippocrates theories to the number of days jesus spent in the wilderness. since then the quarantine process has evolved and is quite effective. the principle is to isolate the infected person until they are beyond the infectious state. for covid-19 it was for 10 days in the asymptomatic persona and up to 21 days for those severely ill or hospitalized. longer times were recommended based on the severity of the disease and the health status of the infected person. an extension of the quarantine principle is social distancing which is based on the effective distance to minimize aerosolization based contamination. initially it was 6 feet for the covd-19, but it has been suggested that it might be increased to 10 feet based on the highly contagious delta variant. the wearing of masks has been around mankind for thousands of years. the use of masks was seen with the dead and at the burial site and funerals. they were used as part of a religious ritual and it is very possible that the masks were actually used to protect from contamination with the dead person's infection. perhaps the most memorable use of masks are the sinister looking masks that were developed from the carnival masks of venice and were used by medieval doctors to protect them against the plague and the black death. of note is that the beak of these masks were used to hold herbs to absorb the noxious air based on the miasma theory of disease propagation. unfortunately there is no proof that this mask was effective. it was principally the use of the masks to cover the mouth and nose during the flu pandemic of 1910 to 1911 and the effectiveness of mandatory masks during the influenza pandemic of 1918 to 1919 that supported the principle that facemasks are a means of protecting medical workers and patients from infectious disease outside of places such as the operating room. while controversial, in the city of san francisco, the decline in deaths from influenza was attributable to the mandatory mask wearing policies. a systematic review med analysis of public health masks to prevent person to person transmission concluded that the facemask had good results with an 85% reduction in risk of infection. the evidence from this review was stronger for the use of face masks as part of the personal protective equipment in the health care settings rather than in the community setting. in addition, the review supported the use of specific masks such as the n95 over the use of surgical or cotton masks. studies particularly based in asian countries such as china and japan have shown some effectiveness in the wearing of masks however the overall effectiveness is a concern due to the lack of consistent compliance throughout the community. despite this the cdc strongly supports the wearing of masks. it is important to point out that these must be worn properly covering both the nares and the mouth, and the mask must be changed if it gets wet. mask changing also requires proper hand hygiene when handling the masks. advocates for wearing the mask believe that they will protect those from individuals who have been infected with covid-19 but are asymptomatic. it is certainly felt that the mask alone is not as effective unless it is part of the complete public health care measures including social distancing, isolation, or quarantine of the infected and proper hand hygiene. one of the most important aspects of public health control of infectious diseases is proper hand hygiene. while religious hand hygiene was around for thousands of years, the idea that hand hygiene was associated with germs, diseases and was a life-saving measure has only been around for about 170 years. this was through the work of ignaz semmelweis who in the vienna obstetrical clinic demonstrated that hand washing reduced the maternal mortality from 18.3% to below 2%. although his work was criticized, in part due to the fact the exact reason for the improvement was not identified, his work was subsequently validated with the work of dr. joseph lister. despite many ups and downs, hand hygiene has been identified as a major public health measure. compliance with hand hygiene has been a moving target requiring constant reminders including in the healthcare settings. the who has identified hand washing as the leading public health measure to control the spread of disease and this is supported by the cdc. the who guidelines emphasizes that clean care is safe care and provides the support for regular hand washing. so how are we doing with this health measure particularly in the health facilities? in the public setting the data shows that we are very poor at hand hygiene. unfortunately in the health facilities the data is also not promising. previous studies have demonstrated hand washing compliance to be only 47.5% across eight hospital surveyed. identifying barriers and addressing them improved the hand washing to 81% which is still low for a hospital. the recent pandemic can have a positive effect on hand hygiene, but the actual compliance is based on the individual’s sex, their perceived susceptibility, and the actual effectiveness of the hand washing. addressing these are very important in improving the hand washing. however, continually personnel in healthcare facilities need to be reminded about the importance and effectiveness of hand washing. that is why it continues to be a key element of the joint commission’s national patient safety goals. so does this meaning that we need to continue to wear masks all the time? no, but we do have to rethink our personal approach to public health measures and infection control. covering ones nose and mouth particularly in doors, respecting social distancing, and performing regular hand hygiene have once again been proven to work and to be effective. the cdc continues to advocate these public health measures as we wait for the global pandemic to subside. we have the opportunity to continue to use these measures to dhrp, 2021, vol. 1 (s5) 4-6 protective effect of public health measures http://dhrproceedings.org 6 © dhr health institute for research and development protect ourselves, our patients and our families from covid-19 and other infectious diseases even as therapies are being instituted: they supplement the therapies. making them part of our regular routine as health care workers is what is really important; and is our responsibility. so, remember what your mother told you: “cover your mouth and nose when you cough or sneeze, stay well away from the sick kids, and wash your hands!” ---as usual she was right! diclosures raf declares no conflicts of interest. aoo declares no conflicts of interest. ms declares no conflicts of interest. funding there is no funding associated with this publication. references 1. cdc on hand washing: ( https://www.cdc.gov/handhygiene/index.html) 2. strasser bj, schlich t. the art of medicine. a history of the medical mask and the rise of the throwaway culture. lancet 2020; 396: 19-20. 3. tognotti e. lessons from the history of quarantine from plague to influenza a. emerging infectious disease 2013; 19:254259. 4. peek k. public health. flu has disappeared worldwide during the covid pandemic. scientific american june 2021 5. zhu y, li w, yang b, qian r, wu f, he x, zhu q, liu q, ni y, wang j, and mao s. epidemiological and virological characteristics of respiratory tract infections in children during covid-19 outbreak. bmc pediatrics 2021; 195:1-8 6. nascimento ms, baggio dm, fascina lp do prado c impact of social isolation due to covid-19 on the seasonality of pediatric respiratory disease. plos one 2020; 15:1-6 (https://dpi.org/10.1371/journal.prone.0243694 ). 7. dwipayanti nmu, lubis ds, and harjana npa. public perception and hand hygiene behavior during covid19 pandemic in indonesia. frontiers of public health 2021; 9:1-12 (doi: 10.3389/fpubh.2021.621800) 8. chassin mr, mayer c, and nether k. improving hand hygiene at eight hospitals in the united states by targeting specific causes of noncompliance. the joint commission journal on quality and patient safety 2015; 41:4-12 9. mathur p. hand hygiene: back to the basics of infection control. indian j med res 2011; 134:611-620 10. chu dk, aki ea, duda s, solo k, yaacoub s, and schunemann hj. physical distancing, face masks, and eye protection to prevent person-to-person transmission of sara-cov-2 and covid-19: a systemic review and meta-analysis. lancet 2020; 395:1973-1987 11. world health organization. who guidelines on hand hygiene in health care: a summary. editors world health organization & who patient safety. who reference number who/ier/psp/2009/01. 12. cdc covid-19 vaccinations; https://www.cdc.gov/vaccines/covid-19/index.html 13. cdc covid-19 protection; https://www.cdc.gov/coronavirus/2019-ncov/index.html 14. who global influenza program: https://www.who.int/teams/global-influenzaprogramme/surveillance-and-monitoring/influenzasurveillance-outputs 15. joint commission national safety goals: ( https://www.jointcommission.org/standards/about-ourstandards/ ) https://www.cdc.gov/handhygiene/index.html https://dpi.org/10.1371/journal.prone.0243694 https://www.cdc.gov/coronavirus/2019-ncov/index.html https://www.who.int/teams/global-influenza-programme/surveillance-and-monitoring/influenza-surveillance-outputs https://www.who.int/teams/global-influenza-programme/surveillance-and-monitoring/influenza-surveillance-outputs https://www.who.int/teams/global-influenza-programme/surveillance-and-monitoring/influenza-surveillance-outputs https://www.jointcommission.org/standards/about-our-standards/ https://www.jointcommission.org/standards/about-our-standards/ 2021, vol. 1 (s5) 11-14 https://doi.org/10.47488/dhrp.v1is5.37 http://dhrproceedings.org 11 © dhr health institute for research and development commentary what is the definition of being fully vaccinated? should the three-dose vaccination with the mrna vaccines be the new standard? sohail rao, md, ma, dphil1, 2 and manish singh, md, facs3 1 executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas 78539 and president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0001-5027-9992 2 correspondence should be addressed to: sohail rao, md, ma, dphil., dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. tel: (956) 362-2387. e-mail: s.rao@dhr-rgv.com 3 chief executive officer, dhr health, 5501 s. mccoll road, edinburg tx 78539 and dhr health bariatric & metabolic institute, 5500 raphael drive, edinburg, tx 79539 orcid: manish singh: https://orcid.org/0000-0003-4146-3282 received 12/10/2021 accepted for publication 12/10/2021 published 12/10/2021 keywords: covid-19; sars-cov-2; b.1.1.529; omicron variant; cdc: canters for disease control and prevention; fda: u.s. food and drug administration; pfizer/biontech; moderna; jansen despite the availability of numerous clinically effective covid-19 vaccines which have been approved and/or authorized for use in humans, mitigating morbidity and mortality associated with the exposure to or infection with sars-cov-2 virus remains an elusive global challenge. it is quite alarming that worldwide, over 5.2 million people have already died as a result of sars-cov-2 infection and over 8,000 continue to meet this tragic fate every day (1). in the us, over 790,000 have died as a result of covid-19 and over 1,000 people are dying every day as a consequence of infection with sars-cov-2 (2). in the us, three covid-19 vaccines have been approved and/or authorized by the fda and the cdc (table 1). using the currently recommended criteria, as of december 10, 2021, 60.5% (>200,000) of the u.s. population has been fully vaccinated (table 1) and 71.5% have received at least one dose of the covid-19 vaccine (2). it is perturbing that multiple clinical studies have demonstrated the decline in vaccine protection against sars-cov-2 infection (3, 4). a large cohort study by chemaitelly, et.al., using subjects who received pfizer vaccine showed that in the first two weeks after the first dose of the vaccine, vaccine effectiveness against the wild-type and any sars-cov-2 variant was undetectable (3). however, seven days later, it increased to 36.8%, peaking at 77.5% in the four weeks after the second dose. interestingly, regardless of the age group, vaccine effectiveness against the wild-type sars-cov-2 and all its variants (including delta) gradually decreased after one month, with the decline accelerating after month four, to only about 20% after five to six months following the second dose (3). in israel, levin, et.al., studied 4,868 vaccinated healthcare workers over the period of approximately six months (4). the subjects were tested monthly for anti-spike immunoglobulin g (igg) and neutralizing antibodies against sars-cov-2. a https://orcid.org/0000-0001-5027-9992 mailto:s.rao@dhr-rgv.com https://orcid.org/0000-0003-4146-3282 dhrp, 2021, vol. 1 (s5) 11-14 definition of fully vaccinated? http://dhrproceedings.org 12 © dhr health institute for research and development table 1: fda and cdc approved and/or authorized covid-19 vaccines in the united states pfizer biontech (comirnatytm) moderna jansen (johnson and johnson) type of vaccine mrna mrna viral vector primary series of immunization two (2) doses 21 days apart two (2) doses 28 days apart one (1) dose approved (age) >16 years no no authorized (age) >5 years >18 years >18 years booster or 3rd dose >16 years* >18 years* >18 years** current definition of fully vaccinated two (2) weeks after 2nd dose two (2) weeks after 2nd dose two (2) weeks after 1st dose *at least six (6) months after completing the primary series of immunization **at least two (2) months after receiving the first dose of the vaccine very small cohort of healthcare workers (0.4%) were diagnosed as having a covid-19 breakthrough infection. the mean igg level during days four through 30 after two pfizer vaccine doses was 29.3 as a sample-to-cutoff ratio. igg concentrations fell substantially each month and had decreased by a factor of 18.3 after six months. similarly, neutralizing antibody titers dropped by a factor of 3.9 between the peak and the end of the study but declined more slowly from months 3 to 6. expressed as a 50% neutralizing level, the mean concentration of neutralizing antibodies was 557.1 at the peak, decreasing to 119.4 by six months. six months after the second dose, neutralizing antibody concentrations were much lower in men than in women (ratio of means [rom], 0.64), those 65 years and older versus those 18 to 44 years (rom, 0.58), and immunosuppressed vaccinees (rom, 0.30). from the peak to the end of the study, substantially lower igg levels were tied to older age, male sex, and the presence of at least two underlying chronic conditions (high blood pressure, diabetes, abnormal cholesterol levels, and heart, lung, kidney, or liver disease), autoimmune disease, and immunosuppression (4). given these clinical observations, the need for a booster dose of the covid-19 vaccine was being seriously contemplated by the scientists and the public policy experts. israel was among the first country to initiate the booster dose of pfizer vaccine for its citizens who were >60 years of age. bar-on, et.al., evaluated over 1.1 million subjects over the age of 60 who had received the booster dose at least five months after completing the primary immunization with the pfizer vaccine (5). those who received the booster were approximately 19.5fold less likely to develop severe covid-19 as compared to a similar age-matched controls who had only received the two dose primary series of immunization. interestingly, booster vaccination not only resulted in significant reduction in severe covid-19, but also reduced (11.3-fold) sars-cov-2 infections (5). similar results supporting the effectiveness of the third dose of the pfizer vaccine in enhancing the protection against sars-cov-2 infections were also reported by barda et al. (6). based on these and similar clinical observations which provided unequivocal evidence underscoring the effectiveness of a booster dose of covid-19 vaccines in enhancing protection against sars-cov-2 infection, on august 12, 2021, fda authorized a 3rd dose of pfizer and/or moderna vaccine for certain immunocompromised individuals (7). this authorization was limited to solid organ transplant recipients or those who are diagnosed with conditions that are considered dhrp, 2021, vol. 1 (s5) 11-14 definition of fully vaccinated? http://dhrproceedings.org 13 © dhr health institute for research and development to have an equivalent level of immunocompromise. on november 19, 2021, cdc modified the authorization allowing booster dose for all adults ages 18 years and older who received a pfizer-biontech or moderna vaccine at least six months after their second dose (8). emergency authorization for pfizer-biontech covid-19 vaccine was further modified by the fda on december 09, 2021, for the pfizer-biontech covid-19 vaccine allowing the use of a single booster dose for administration to individuals 16 and 17 years of age at least six months after completion of primary vaccination with the pfizer-biontech covid-19 vaccine (9). the recent identification of omicron (5.1.1.529) variant of sars-cov-2 from southern african nations and its rapid spread across the globe has alarmed the scientific community and the public health experts (10-12). this has also called to question the efficacy of the existing covid-19 vaccines in affording protection against this variant. a team of scientists from the africa health research institute tested 14 plasma samples from 12 participants, with 6 having no previous history of sars-cov-2 infection and all were previously vaccinated with two doses of pfizer/biontech vaccine (13). the results showed a 41-fold decline in antibodies generated by the pfizer vaccine to neutralize the omicron variant as compared to the delta variant of sars-cov-2. interestingly, antibodies in the blood from the six volunteers who had previous sars-cov-2 infection and were subsequently vaccinated were better able to neutralize the virus (13). the possibility of immune evasion by the omicron variant has also been predicted by artificial intelligence models that have been extensively validated (14). based on 132 threedimensional structures of antibody-receptor binding complexes, it was suggested that omicron may be twice more likely to escape current vaccines as compared to the delta variant. in an independent study, pfizer has claimed that three doses of pfizer-biontech covid-19 vaccine (group b, figure 1) effectively neutralized the omicron variant while two doses (group a, figure 1) showed significantly reduced neutralization titers (15). additionally, the data also indicated that the third dose of the pfizer/biontech covid-19 vaccine increased the neutralizing antibody titers by 25-fold as compared to two doses against the omicron variant. from the foregoing scientific evidence, we conclude that to afford effective protection against various variants of the sars-cov-2, at a minimum three doses of pfizer or moderna and two doses of jansen vaccine would be required. in fact, we had previously argued that the pfizer/biontech or moderna covid-19 vaccines should have been authorized by the fda as a three dose primary vaccination series. likewise, we had also previously suggested that jansen covid-19 vaccine should have been a two dose primary vaccination series. considering the available data, we are also recommending that booster dose should be authorized for children 5-15 years of age ensuring that they are also protected against the sars-cov-2 variants. lastly, we are also recommending that the definition of fully vaccinated be revised to include three doses of pfizer/biontech or moderna and two doses of jansen covid-19 vaccines. it is not entirely inconceivable that in the very near future, we may require additional doses of covid-19 vaccine that has been tailored to neutralize evolving sars-cov-2 variants. figure 1: experimental design to determine the capacity of antibodies to neutralize omicron (b.1.1.529) variant of sars-cov-2 in subjects vaccinated with two doses (group a) or three doses (group b) of pfizer/biontech vaccine diclosures sr declares no conflicts of interest. ms declares no conflicts of interest. references 1. who coronavirus (covid-19) dashboard. https://covid19.who.int/ (accessed on december 09, 2021; 15:40 hrs) 2. covid data tracker. centers for disease control and prevention. cdc data tracker. (accessed on december 09, 2021; 15:50 hrs) https://covid19.who.int/ https://covid.cdc.gov/covid-data-tracker/#datatracker-home dhrp, 2021, vol. 1 (s5) 11-14 definition of fully vaccinated? http://dhrproceedings.org 14 © dhr health institute for research and development 3. chemaitelly h, tang p, hasan mr, et. al. waning of bnt162b2 vaccine protection against sars-cov-2 infection in qatar. n. engl j med 2021; 385:e83. doi: 10.1056/nejmoa2114114 4. levin eg, lustig y, cohen c, et. al. waning immune humoral responses to bnt162b2 covid-19 vaccine over 6 months. n. eng j med 2021; 385:e84 doi: 10.1056/nejmoa2114583 5. bar-on ym, goldberg y, mandel m, et.al. protection of bnt162b2 vaccine booster against covid-19 in israel. n engl j med 2021; 385:1393-1400 doi: 10.1056/nejmoa2114255 6. barda n, dagan n, cohen c, et.al. effectiveness of a third dose of the bnt162b2 mrna covid-19 vaccine for preventing severe outcomes in israel: an observational study. lancet 2021; 398: 2093-100. doi: 10.1016/s0140-6736(21)02249-2 7. coronavirus (covid-19) update: fda authorizes additional vaccine dose for certain immunocompromised individuals. aug 12, 2021. fda news release. 8. cdc expands eligibility for covid-19 booster shots to all adults. nov 19, 2021. cdc news release. 9. coronavirus (covid-19) update: fda expands eligibility for pfizer-biontech covid-19 booster dose to 16 and 17 year olds. dec 09, 2021. fda news release. 10. cheng, m. what is this new covid variant in south africa. november 26, 2021. associated press. https://www.aol.com/explainer-covid-variant-southafrica-111307372-142856393.html 11. classification of omicron (b.1.1.529): sars-cov-2 variant of concern. world health organization. november 26, 2021. who statement 12. statement from president joe biden on the omicron covid-19 variant. the white house. november 26, 2021. whitehouse statement 13. cele s, jackson l, khan k, et.al. sars-cov-2 omicron has extensive but incomplete escape of pfizer bnt 162b2 elicited neutralization and requires ace2 for infection. medrxiv 2021.12.08.21267417; doi: 10.1101/2021.12.08.2126741715 14. chen j, wang r, gilby nb, wei gw. omicron (b.1.1.529): infectivity, vaccine breakthrough, and antibody resistance. arxiv [preprint]. 2021 dec 1:arxiv:2112.01318v1. pmid: 34873578; pmcid: pmc8647651. 15. pfizer and biontech provide update on omicron variant. dec 08, 2021. pfizer/biontech news release https://www.nejm.org/doi/10.1056/nejmoa2114114 https://www.nejm.org/doi/full/10.1056/nejmoa2114583 https://www.nejm.org/doi/10.1056/nejmoa2114255 https://www.thelancet.com/pdfs/journals/lancet/piis0140-6736(21)02249-2.pdf https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-vaccine-dose-certain-immunocompromised https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-vaccine-dose-certain-immunocompromised https://www.cdc.gov/media/releases/2021/s1119-booster-shots.html https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-expands-eligibility-pfizer-biontech-covid-19-booster-dose-16-and-17 https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-expands-eligibility-pfizer-biontech-covid-19-booster-dose-16-and-17 https://www.aol.com/explainer-covid-variant-south-africa-111307372-142856393.html https://www.aol.com/explainer-covid-variant-south-africa-111307372-142856393.html https://www.who.int/news/item/26-11-2021-classification-of-omicron-(b.1.1.529)-sars-cov-2-variant-of-concern https://www.whitehouse.gov/briefing-room/statements-releases/2021/11/26/statement-by-president-joe-biden-on-the-omicron-covid-19-variant/ https://www.medrxiv.org/content/10.1101/2021.12.08.21267417v1 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8647651/ https://www.pfizer.com/news/press-release/press-release-detail/pfizer-and-biontech-provide-update-omicron-variant 2021, vol. 1 (s4) 9-10 https://doi.org/10.47488/dhrp.v1is4.24 http://dhrproceedings.org 9 © dhr health institute for research and development editorial why should vaccinated people wear masks indoors in areas of high community transmission? rationale for cdc’s recent recommendation on april 27, 2021, the centers for disease control & prevention (cdc) recommended that individuals who are fully vaccinated do not have to wear their masks when outdoors unless they are in crowded gathering. as more data became available, on june 15, 2021, the cdc updated their advisory further easing masking restrictions for vaccinated individuals. as part of this new advisory, masking was not required (both indoors and outdoors) for vaccinated individuals except for certain conditions in which it was mandatory for all irrespective of their vaccination status. the latter included the requirement to mask while using public transit; in healthcare facilities; correctional and detention facilities; homeless shelters; and in k-12 facilities. this latest cdc advisory was viewed as an affirmative consequence of vaccination placing greater burden on people to get vaccinated. the recent surge in infections with the sars-cov2 delta (b.1.617.2) variant and the evolving public health crisis has prompted the cdc to reconsider and reverse its earlier advisory about masking for vaccinated individuals (1). the interim recommendations issued on july 27, 2021, stated that fully vaccinated people wear a mask in public indoor settings in areas of substantial or high transmission which includes all counties in the greater rio grande valley (2). it was also recommended that fully vaccinated people might choose to wear a mask regardless of the level of transmission, particularly if they are immunocompromised or at increased risk for severe disease from covid-19, or if they have someone in their household who is immunocompromised, at increased risk of severe disease or not fully vaccinated. lastly, it was recommended that fully vaccinated people who have a known exposure to someone with suspected or confirmed covid-19 be tested 3-5 days after exposure, and to wear a mask in public indoor settings for 14 days or until they receive a negative test result. it is notable that the majority of those recently diagnosed with covid-19 fall in two distinct categories; unvaccinated and those who are vaccinated but have complicating risk factors (such as old age, diabetes, obesity, hypertension, immunosuppressed, etc.). the population most seriously affected are those who are unvaccinated. given its high transmissibility and infectivity, the delta variant is indifferent to the age of the patient as many newly diagnosed cases are in younger age groups including children. more importantly, majority of patients who are hospitalized with severe covid-19 disease are those who are unvaccinated. on the contrary, vaccinated patients tend to develop mild sars-cov-2 infection which rarely requires hospitalization. in fact, most recent cdc data suggests that if infected, 99.99% of vaccinated individuals do not require hospitalization. this latest cdc advisory has understandably created some confusion among vaccinated individuals and has given voice to those who oppose vaccination arguing untenably that covid19 vaccination is not protective against sarscov-2 infection. however, there is a reasonable scientific rationale for this advisory as various vaccines work differently in providing protection against the disease. for example, after vaccination against measles and mumps, a person is granted immunity for life. on the contrary, in the case of influenza virus that causes seasonal flu, vaccination must be repeated year after year. interestingly, even after vaccination against flu, people develop mild disease which rarely progresses to a state that necessitates hospitalization. the reason for this “breakthrough” infection is the inherent ability of the infecting agent (in this case the influenza virus) dhrp, 2021, vol. 1 (s4) 1-3 editorial http://dhrproceedings.org 10 © dhr health institute for research and development to mutate and escape the vaccinated individual’s immune response. this is precisely what is being encountered in vaccinated individuals infected with the delta variant. the 13-17 mutations endow the delta variant with the ability to enhance its transmissibility and infectivity and to delude the immune system thus resulting in infection. like many other vaccines, covid-19 vaccination also does not prevent the individual from getting infected, but it will most certainly prevent the development of serious disease that may require hospitalization. therefore, it is important for both vaccinated and unvaccinated individuals to wear mask as recommended by the cdc and for those who are unvaccinated…get vaccinated (if you qualify) as soon as possible…it may save your life! references 1. interim public health recommendations for fully vaccinated people.https://www.cdc.gov/coronavirus/2019ncov/vaccines/fully-vaccinated-guidance.html. (accessed on august 01, 2021, at 4:20 p.m., central standard time) 2. covid-19 integrated county view. https://covid.cdc.gov/coviddata-tracker/#county-view (accessed on august 01, 2021, at 4:32 p.m., central standard time) sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 manish singh, md, facs chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas disclosures: none orcid: manish singh: https://orcid.org/0000-00034146-3282 mailto:s.rao@dhr-rgv.com https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0003-4146-3282 https://orcid.org/0000-0003-4146-3282 2022, vol. 2 (s1) 1-3 https://doi.org/10.47488/dhrp.v2is1.40 http://dhrproceedings.org 1 © dhr health institute for research and development commentary can we abandon our masks? deciphering cdc’s new guidelines about masking in the era of covid-19 pandemic sohail rao, md, ma, dphil1, 2 , khushboo hemnani3, carlos arroyo4 and manish singh, md, facs5 1 executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas 78539 and president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0001-5027-9992 2 correspondence should be addressed to: sohail rao, md, ma, dphil., dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. tel: (956) 362-2387. e-mail: s.rao@dhr-rgv.com 3research academy, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0003-4830-4815 4research academy, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. 5chief executive officer, dhr health, 5501 s. mccoll road, edinburg tx 78539 and dhr health bariatric and metabolic institute, 500 raphael drive, edinburg, tx 78539 orcid: manish singh: https://orcid.org/0000-0003-4146-3282 received 02/28/2022 accepted for publication 02/28/2022 published 02/28/2022 keywords: covid-19; sars-cov-2; cdc, fda, eua, mask sars-cov-2 has infected over 434 million and has claimed the lives of over 5.9 million people worldwide (1). in the united states, over 78.9 million have been infected with sars-cov-2 and over 948,000 people have died from covid-19. since the issuance of the first emergency use authorization by the us food and drug administration (fda) for the use of pfizer/biontech covid-19 mrna vaccine on december 11, 2020, over 215 million people have been fully vaccinated in united states and over 94 million have received a booster dose (2, 3). despite of these accomplishments, in the last 28 days, in the united states, over 4.6 million people have been infected with this virus with over 61,000 deaths reported (1). covid-19 is by far the worst pandemic that the world has witnessed and given the recent data, there appears to be no immediate reprieve in sight. in an attempt to mitigate the spread of covid-19, cdc has issued several guidelines which included wearing of masks in public gatherings (4, 5). despite of all the evidence that masks are critical to lessen the spread of respiratory viruses such as sars-cov-2, the wearing of face masks has become one of the most contentious issues in the united states (6-8). on may 18, 2021, texas governor greg abbott issued an executive order prohibiting government entities from mandating masks (9). since then, with the exception of healthcare facilities, and despite cdc guidelines to the contrary, many organizations have abolished the mandate for indoor masking. consequently, many states in the united states have or will in the very near future eliminate the mandate for indoor masks as well as in the schools (10). on friday, february 25, cdc announced updated guidance on covid-19 prevention and masking with a new framework for measuring community transmission of the disease. the new guidance means that a substantial portion of the u.s. population will no longer be advised to wear a mask in public and in indoor settings (11). most of the cdc’s changes are based on its community level tool, which measures covid risks in every us and puerto rican counties and helps individuals determine the amount of protection they should use depending on where they live, go https://orcid.org/0000-0001-5027-9992 mailto:s.rao@dhr-rgv.com https://orcid.org/0000-0003-4830-4815 https://orcid.org/0000-0003-4146-3282 dhrp, 2022, vol. 2 (s1) 1-3 cdc mask mandate http://dhrproceedings.org 2 © dhr health institute for research and development to work or school, and travel. considering increasing immunity to the virus and variants like omicron, the agency overhauled its benchmarks for three community levels: “high” (orange), “medium” (yellow), and “low” (green). under the new system, 70 percent of americans are outside of orange zones and can, in theory, stop masking up indoors (figure 1). figure 1: state and county-level covid-19 community levels interactive tool published by the cdc on february 24, 2022 and updated on february 25, 2022 (https://www.cdc.gov/coronavirus/2019ncov/science/community-levels.html) the cdc’s guide now only recommends widespread mask use, regardless of vaccination status, in high-risk areas. previously, this advice also applied to the “substantial” covid community level, which fell between high and medium. substantial is no longer marked as a level on the tool. when the community level tool was first launched in early 2021, the categories were defined by case numbers and transmission rates in counties and states. now the metrics only draw from covid hospitalizations and occupied inpatient beds in a locality. according to rochelle walensky, director of the cdc “this new framework moves beyond just looking at cases and test positivity to evaluate factors that reflect the severity of disease, including hospitalizations and hospital capacity, and helps to determine whether the level of covid-19 and severe disease are low, medium, or high in a community. the covid-19 community levels we are releasing today will inform cdc measures like masking … this updated approach focuses on directing our prevention efforts toward protecting people at high risk of severe illness and preventing hospital and health care systems from being overwhelmed.” but even with relaxed precautions, the cdc states that people should take personal risk into account when deciding whether to mask up in public. for example, under the medium community level guidance, the agency says: “if you are immunocompromised or at high risk for severe illness, talk to your healthcare provider about additional precautions, such as wearing masks or respirators indoors in public.” however, it doesn’t identify extra masking protocols for adults and older kids who haven’t been vaccinated. to date, nearly 14 percent of the us population has not received a single covid-19 vaccine shot. despite the shifting guidelines from the cdc and states, masks are always an option for individuals looking to protect themselves and others from the virus. it is important to note that healthcare facilities, businesses, school districts, transit authorities, and workplaces might have their own indoor masking requirements independent of state mandates that need to be followed. it must be recognized that all four counties (hidalgo, cameron, willacy, and starr) in the rio grande valley are considered high risk for covid-19 transmission. in fact, the four surrounding counties of kenedy, brooks, jim hogg and zapata are also considered high risk (figure 1). for people living in high-risk areas such as the south texas, cdc has recommended the following (12): • wear a well-fitting mask indoors in public, regardless of vaccination status (including in k-12 schools and other indoor community settings) • if you are immunocompromised or high risk for severe disease: o wear a mask or respirator that provides you with greater protection o consider avoiding non-essential indoor activities in public where you could be exposed o talk to your healthcare provider about whether you need to wear a mask and take other precautions (e.g., testing) o have a plan for rapid testing if needed (e.g., having home tests or access to testing) o talk to your healthcare provider about whether you are a candidate for treatments like oral antivirals, pre-exposure prophylaxis, and/or monoclonal antibodies • if you have household or social contact with someone at high risk for severe disease: o consider self-testing to detect infection before contact o consider wearing a mask when indoors with them https://www.cdc.gov/coronavirus/2019-ncov/science/community-levels.html https://www.cdc.gov/coronavirus/2019-ncov/science/community-levels.html dhrp, 2022, vol. 2 (s1) 1-3 cdc mask mandate http://dhrproceedings.org 3 © dhr health institute for research and development • stay up to date with covid-19 vaccines and boosters • maintain improved ventilation throughout indoor spaces when possible • follow cdc recommendations for isolation and quarantine, including getting tested if you are exposed to covid-19 or have symptoms of covid-19 we strongly endorse cdc’s recommendations and request that people in the valley use their personal discretion in the use of mask in indoor and public settings. this is particularly important for individuals who are unvaccinated and/or immunocompromised and are at high risk for getting infected with sars-cov-2. diclosures sr declares no conflicts of interest. kh declares no conflicts of interest. ca declares no conflicts of interest. ms declares no conflicts of interest. funding the project is funded by a seed grant from the dhr health institute for research & development references 1. covid-19 dashboard. john hopkins university of medicine. 2021. https://coronavirus.jhu.edu/map.html (accessed february 27, 2022; 13:11 hrs cst) 2. fda takes key action in fight against covid-19 by issuing emergency use authorization for first covid19 vaccine. december 11, 2020. https://www.fda.gov/news-events/pressannouncements/fda-takes-key-action-fight-againstcovid-19-issuing-emergency-use-authorization-firstcovid-19 3. covid-19 vaccination in the united states. covid-19 tracker. centers for disease control and prevention. https://covid.cdc.gov/covid-datatracker/#vaccinations_vacc-people-onedose-pop-5yr 4. use and care of masks, centers for disease control and prevention. https://www.cdc.gov/coronavirus/2019ncov/prevent-getting-sick/about-facecoverings.html?cdc_aa_refval=https%3a%2f%2fw ww.cdc.gov%2fcoronavirus%2f2019-ncov%2fpreventgetting-sick%2fcloth-face-cover-guidance.html 5. stop the spread. centers for disease control and prevention. https://www.cdc.gov/coronavirus/2019ncov/communication/stop-the-spread.html 6. li y, liang m, gao l, ayaz ahmed m, uy jp, cheng c, zhou q, sun c. face masks to prevent transmission of covid-19: a systematic review and meta-analysis. am j infect control. 2021 jul;49(7):900-906. doi: 10.1016/j.ajic.2020.12.007. epub 2020 dec 19. pmid: 33347937; pmcid: pmc7748970. 7. hemmer cj, hufert f, siewert s, reisinger e. protection from covid-19–the efficacy of face masks. dtsch arztebl int. 2021 feb 5;118(5):59-65. doi: 10.3238/arztebl.m2021.0119. pmid: 33785117; pmcid: pmc8188409. 8. how did face masks become a political issue in america? guardian. june 29, 2020. https://www.theguardian.com/world/2020/jun/29/facemasks-us-politics-coronavirus 9. governor abbott issues executive order 36 prohibiting government entities from mandating masks. office of the texas governor – greg abbott. may 18, 2021. https://gov.texas.gov/news/post/governor-abbott-issuesexecutive-order-36-prohibiting-government-entitiesfrom-mandating-masks 10. soon only one u.s. state will still have an indoor mask mandate. cbs news. february 23, 2022, https://www.wltx.com/article/news/health/coronavirus/st ates-drop-indoor-mask-mandates/101-69b72ae7-2b8e45a6-ad47-fbfa9aa0daff 11. new cdc guidance ends mask recommendation for most u.s. counties. national review. february 25, 2022. https://www.nationalreview.com/news/new-cdcguidance-ends-mask-recommendation-for-most-u-scounties/ 12. covid-19 community levels: a measure of the impact of covid-19 illness on health and healthcare systems. centers for disease control and prevention. february 25, 2022. https://www.cdc.gov/coronavirus/2019ncov/science/community-levels.html https://coronavirus.jhu.edu/map.html https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19 https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19 https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19 https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19 https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-onedose-pop-5yr https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-onedose-pop-5yr https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2f2019-ncov%2fprevent-getting-sick%2fcloth-face-cover-guidance.html https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2f2019-ncov%2fprevent-getting-sick%2fcloth-face-cover-guidance.html https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2f2019-ncov%2fprevent-getting-sick%2fcloth-face-cover-guidance.html https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2f2019-ncov%2fprevent-getting-sick%2fcloth-face-cover-guidance.html https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2f2019-ncov%2fprevent-getting-sick%2fcloth-face-cover-guidance.html https://www.cdc.gov/coronavirus/2019-ncov/communication/stop-the-spread.html https://www.cdc.gov/coronavirus/2019-ncov/communication/stop-the-spread.html https://www.theguardian.com/world/2020/jun/29/face-masks-us-politics-coronavirus https://www.theguardian.com/world/2020/jun/29/face-masks-us-politics-coronavirus https://gov.texas.gov/news/post/governor-abbott-issues-executive-order-36-prohibiting-government-entities-from-mandating-masks https://gov.texas.gov/news/post/governor-abbott-issues-executive-order-36-prohibiting-government-entities-from-mandating-masks https://gov.texas.gov/news/post/governor-abbott-issues-executive-order-36-prohibiting-government-entities-from-mandating-masks https://www.wltx.com/article/news/health/coronavirus/states-drop-indoor-mask-mandates/101-69b72ae7-2b8e-45a6-ad47-fbfa9aa0daff https://www.wltx.com/article/news/health/coronavirus/states-drop-indoor-mask-mandates/101-69b72ae7-2b8e-45a6-ad47-fbfa9aa0daff https://www.wltx.com/article/news/health/coronavirus/states-drop-indoor-mask-mandates/101-69b72ae7-2b8e-45a6-ad47-fbfa9aa0daff https://www.nationalreview.com/news/new-cdc-guidance-ends-mask-recommendation-for-most-u-s-counties/ https://www.nationalreview.com/news/new-cdc-guidance-ends-mask-recommendation-for-most-u-s-counties/ https://www.nationalreview.com/news/new-cdc-guidance-ends-mask-recommendation-for-most-u-s-counties/ https://www.cdc.gov/coronavirus/2019-ncov/science/community-levels.html https://www.cdc.gov/coronavirus/2019-ncov/science/community-levels.html 2021, vol. 1 (s4) 1-3 https://doi.org/10.47488/dhrp.v1is4.17 http://dhrproceedings.org 1 © dhr health institute for research and development editorial should healthcare facilities mandate covid-19 vaccination of its employees? there has been a lot of controversy recently surrounding the decision by a major healthcare facility in houston, texas mandating that all of its 26,000 employees must be vaccinated against sars-cov-2 virus by june 07, 2021, or else face suspension and/or dismissal (1). it was the first major hospital system in the u.s., to take this rather bold decision particularly since the covid-19 vaccine is currently being administered under an emergency use authorization (eua) issued on december 11, 2020, by the u.s. food and drug administration (2). houston methodist hospital has taken this decision in the best interest of patient safety arguing that it is a complex, team-oriented responsibility requiring active effort of every member of the healthcare team. needless to say, patient safety is the most vital and tacit contract between the healthcare providers and the patients and it is the core element of the principle of nonmalfeasance – do no harm which dictates the practice of medicine and is the legal and ethical framework to which all healthcare workers ascribe. what has been the outcome of this decision and what are its ethical and legal manifestations? since houston methodist announced their decision to mandate covid-19 vaccination for all of its employees, over 1,200 employees have voluntarily left the organization and another 117 have filed a lawsuit against the healthcare facility in the texas high court challenging this directive (3). in this lawsuit, the employees have argued that their employer's compulsory immunization requirement violated the nuremberg code, a set of standards designed after world war two to prevent experimentation on human subjects without their consent (4). they have also declared that the hospital presented them with the choice of either getting a vaccine or losing their job, which violated state law, and demanded that the court prevent houston methodist from firing unvaccinated staffers. it has been argued that since the covid-19 vaccines are being administered under an eua, therefore their use must be considered experimental. it is important to emphasize that the process to issue eua for covid-19 vaccines involved a very rigorous scientific review by a panel of independent experts both at the level of the fda and the centers for disease control & prevention. in this process, data from randomized placebocontrolled studies involving over 100,000 adults using various covid-19 vaccines was meticulously evaluated for both safety and efficacy (5, 6). subsequently, similar randomized placebocontrolled studies in pregnant women and adolescents also yielded analogous outcomes and confirmed the safety and the efficacy of these vaccines (7, 8). the safety and efficacy of the covid-19 vaccines has also been confirmed by mass vaccinations in the u.s. as of june 7, 2021, over 301 million doses of vaccines have been administered in the u.s. with minimal adverse events (9). in texas alone, as of june 07, 2021, over 22 million doses of covid-19 vaccines have been administered with similar safety outcomes (10). it is noteworthy that safety and efficacy of two of the three approved covid-19 vaccines in the u.s., has also prompted both pfizer-biontech and moderna to apply for full fda approval of their respective vaccines (11, 12). the issue of legality of mandating vaccination in the face of a public health crisis was addressed by the u.s. supreme court during the smallpox epidemic in the city of cambridge, massachusetts in 1905 (13). in the case jacobson v. massachusetts, the u.s. supreme court upheld the right of the city of cambridge, massachusetts, to mandate vaccination against smallpox. rejecting the contention that mandatory vaccination violated an individual's rights to due process and equal protection as guaranteed by the 14th amendment of the u.s. constitution, the court held that states may limit https://doi.org/xxxx/xxxx dhrp, 2021, vol. 1 (s4) 1-3 editorial http://dhrproceedings.org 2 © dhr health institute for research and development individual liberty in the service of well-established public health interventions. for over 100 years, this seminal opinion has served as the constitutional foundation for state actions limiting liberty in the name of public health. additionally, on may 28, 2021, the u.s. equal employment opportunity commission (eeoc) provided an updated guidance for covid-19 vaccination (14). in this guidance, eeoc provided four key updates which included the following (adopted from the eeoc guidance): a) federal eeo laws do not prevent an employer from requiring all employees physically entering the workplace to be vaccinated for covid-19, so long as employers comply with the reasonable accommodation provisions of the american with disabilities act and title vii of the civil rights act of 1964 and other eeo considerations b) federal eeo laws do not prevent or limit employers from offering incentives to employees to voluntarily provide documentation or other confirmation of vaccination obtained from a third party (not the employer) in the community, such as a pharmacy, personal health care provider, or public clinic c) employers that are administering vaccines to their employees may offer incentives for employees to be vaccinated, as long as the incentives are not coercive d) employers may provide employees and their family members with information to educate them about covid-19 vaccines and raise awareness about the benefits of vaccination it is predictable that to ensure patient safety, conversations to mandate covid-19 vaccinations for workers are ongoing in many healthcare facilities across the u.s. a recent cnn report also implied that using rationale similar to that adopted by the houston methodist hospital, two other major healthcare organizations in houston, texas are seriously considering implementing this mandate (15). physicians, policymakers, and public health officials must engage in robust discussions related to legal and ethical issues encompassing mandated covid-19 vaccination of healthcare employees. these intrepid actions are vital to protect the public and the patients from emerging and reemerging infectious diseases and other similar threats. in this informed decision-making process, it will be instructive to revisit lessons learned from current and previous pandemics and to use them as a guide to design and implement an effective, scalable and a sustainable model that is in the best interest of the public and the patients. references 1. medley, a. houston methodist hospital makes covid-19 vaccination mandatory for all employees. april 1, 2021. https://www.chron.com/coronavirus/article/houstonmethodist-covid-19-mandatory-vaccine-16070061.php 2. pfizer-biontech covid-19 vaccine emergency use authorization – letter of authorization. https://www.fda.gov/media/144412/download 3. harkins, d. 117 staffers sue over houston hospital’s vaccine mandate, saying they don’t want to be ‘guinea pigs’. may 29, 2021. https://news.yahoo.com/117-staffers-sue-over-houston210313560.html 4. trials of war criminals before the nuremberg military tribunals under control council law no. 10", vol. 2, pp. 181182. washington, d.c.: u.s. government printing office, 1949. https://archive.org/details/trialsofwarcriminalsbeforethenur embergmilitarytribunalsundercontrolcouncil/trials%20of% 20war%20criminals%20before%20the%20nuremberg%20mil itary%20tribunals%20under%20control%20council%20law %20no.%2010.%20%20nuremberg%2c%20october%201946%20april%2c%201949%20volume%2010/page/n3/mode/2up 5. polack, f.p., thomas, s.j., kitchin, n., et al., for the c4591001 clinical trial group safety and efficacy of the bnt162b2 mrna covid-19 vaccine. december 31, 2020. n engl j med 2020; 383:2603-2615. doi: 10.1056/nejmoa2034577 6. baden, l. r., el sahly, h.m., essink, b., et al. efficacy and safety of the mrna-1273 sars-cov-2 vaccine. n engl j med. 2021 feb 4;384(5):403-416. doi: 10.1056/nejmoa2035389. epub 2020 dec 30. 7. shimabukuro, t.t., kim, s.y., myers, t.r., et al., for the cdc v-safe covid-19 pregnancy registry team.preliminary findings of mrna covid-19 vaccine safety in pregnant persons. april 21, 2021. n engl j med 2021: 1-10. doi: 10.1056/nejmoa2104983 8. frenck, jr, r.w., klein, n.p., kitchin, n., et.al., for the c4591001 clinical trial group, safety, immunogenicity, and efficacy of the bnt162b2 covid-19 vaccine in adolescents. may 27, 2021. n engl j med 2021: 1-10. doi: 10.1056/nejmoa2107456 9. centers for disease control & prevention covid-19 data tracker. june 07, 2021. https://covid.cdc.gov/covid-datatracker/#vaccinations dhrp, 2021, vol. 1 (s4) 1-3 editorial http://dhrproceedings.org 3 © dhr health institute for research and development 10. texas health & human services covid-19 vaccination dashboard. june 03, 2021. https://tabexternal.dshs.texas.gov/t/thd/views/covid19vaccineintexasdashboard/summary?:origin=card_share_li nk&:embed=y&:isguestredirectfromvizportal=y 11. edwards, e. pfizer, biontech ask fda for full approval of covid-19 vaccine. may 07, 2021. https://www.nbcnews.com/health/health-news/pfizer-asks-fdafull-approval-its-covid-19-vaccine-n1266569 12. lovelace, b., jr. moderna applies for full fda approval of its covid-19 vaccine. june 01, 2021. https://www.nbcnews.com/health/health-news/pfizer-asks-fdafull-approval-its-covid-19-vaccine-n1266569 13. jacobson v. massachusetts, 197 u.s. 11 (1905) https://supreme.justia.com/cases/federal/us/197/11/ 14. eeoc issues updated covid-19 technical assistance. https://www.eeoc.gov/newsroom/eeoc-issues-updated-covid19-technical-assistance 15. andrew, s. a texas hospital system will require employees to get the covid-19 vaccine and could fire them if they don't comply. cnn: updated 3:44 pm et, mon april 26, 2021. https://www.cnn.com/2021/04/26/us/houston-methodist-covidvaccine-mandate-trnd/index.html, et.al. recent combined hormonal contraceptives (chcs) and the risk of thromboembolism and other cardiovascular events in new users. contraception. 2013 jan;87(1):93-100. doi: 10.1016/j.contraception.2012.09.015. epub 2012 oct 19. pmid: 23083525. 9. cheng y-j, liu z-h, yao f-j, zeng w-t, zheng d-d, dong yg, et al. (2013) current and former smoking and risk for venous thromboembolism: a systematic review and metaanalysis. plos med 10(9): e1001515. https://doi.org/10.1371/journal.pmed.1001515 sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 manish singh, md, facs chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas disclosures: none orcid: manish singh: https://orcid.org/0000-00034146-3282 https://doi.org/10.1371/journal.pmed.1001515 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0003-4146-3282 https://orcid.org/0000-0003-4146-3282 special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.51 dhr proceedings ǀ http://dhrproceedings.org 20 2022, vol. 2 no. s2 20-22 commentary how did covid-19 affect the mental health of healthcare workers? daniella garcia1,2, eleana alonso1,3, kaylen sauceda1,4, joshua rivera1,3, yuliana valadez1,5, oliver ledezma1,6 1 2nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2 san benito high school, san benito, tx 3 weslaco high school, weslaco, tx 4 harlingen high school south, harlingen, tx 5 zapata high school, zapata, tx 6 port isabel high school, port isabel, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 06/17/2022 accepted for publication 07/14/2022 published 07/14/2022 keywords: covid-19 disease; mental health; healthcare workers introduction what started out as an epidemic in december 2019, covid-19 soon became our new reality when it became a global pandemic. during this time, healthcare workers around the world began experiencing mental illnesses such as depression (77.6%), insomnia (50.4%), and anxiety 7(60.2%) due to the pandemic [1]. the pressure of saving lives, the demand for aid, and the restless nights began to become overbearing. as humanity started to panic and the world began to slowly shut down, society relied on our healthcare practitioners to save us. essential workers among the medical professionals who were overwhelmed by the covid-19 pandemic were those who worked on the front lines such as nurses, doctors, pharmacists, and respiratory therapists. a healthcare provider is a person or entity that provides medical care or treatment for the sick or injured [2]. the community heavily relied on healthcare providers during the pandemic to treat patients infected with sars-cov-2 and healthcare facilities offered higher wages as the first step to improve employee retention in healthcare. frontline healthcare workers had enormous responsibilities beyond patient care, including mass covid testing for large populations, hosting vaccine clinics, acting as liaisons between patients and their families, and educating the public about sars-cov-2 transmission and treatment. these burdens caused healthcare workers to be greatly overworked and led to physical and emotional exhaustion. garcia, et al. covid-19 and mental health of healthcare workers https://doi.org/10.47488/dhrp.v2is2.51 dhr proceedings ǀ http://dhrproceedings.org 22 2022, vol. 2 no. s2 20-22 social and emotional impact rising mental health challenges were reported by these professionals including: posttraumatic stress, burnout, depression, and anxiety. this was due to their occupational activities during and after the pandemic [3]. countless reviews have been conducted on healthcare workers' mental health throughout the covid-19 pandemic. a recent literature review identified 13 studies that reported that 1 out of every 5 health care workers have insomnia [3]. other researchers identified 20 studies that concluded that healthcare workers generally reported more anxiety, depression, and sleep problems, compared to the general population [3]. healthcare workers have been at risk of emotional strain and physical exhaustion from the provision of care to the increasing numbers of patients, who rapidly deteriorated [4]. in their work environment, they had a higher chance of being exposed to critical illnesses and fearing the death of their co-workers [4]. nurses were obligated to work in the frontline and risked being exposed and infected with sars-cov-2. nurses had to cope with not only their physical well-being but also their emotional well-being. a study shows that a total of 34.1% of nurses suffer from emotional exhaustion, and 12.6% suffer from depression [5]. workload while they worked, healthcare workers experienced irregular hours and higher workloads, as they had entered new or unfamiliar clinical roles [6]. the extreme pressures that were experienced by healthcare workers during a pandemic had increased their risk of burnout, which has adverse outcomes, not only for individuals' well-being but also for patient care and the healthcare system [6]. workloads in the night shifts were significantly higher, compared to rotational and morning shifts [7]. 8 hour shifts compared to 12 hours had lower mental workloads [7]. nurses caring for patients who contract coronavirus disease have experienced significant traumas in the form of increased workloads, negative patient outcomes, and less social support system access [8]. this leads them to become paranoid about the risk of exposure towards loved ones. pre-covid, nurses had to do total care on a patient with a 1:1 ratio. as the number of nurses gradually decreased, due to the rise of covid-19, the number of patients outnumbered the number of nurses, resulting in a 1:4 ratio [9]. the increased number of patients per nurse led to job dissatisfaction and position burnouts [10]. burnout causes health professionals to leave, resulting in shortages that affect the mental health of those left behind. they were more likely to feel fatigued compared to other healthcare workers, and were concerned about exposing family members they lived with to covid-19. resource shortages the lack of full protection of nurses across the health industry has raised ethical questions such as the extent of their duty, scarce resources, and the failure of personal protective equipment [11]. they were faced with deciding which patient to save and which they had to watch suffer. a severe shortage in gloves, medical masks, goggles, and face shields struck fear of the thought of infecting themselves or loved ones. in order to protect themselves and their families many health care workers resigned. this resulted in a significant decline in workers in the healthcare field. not only was there not enough equipment, now there were not enough essential workers. conclusion there has been a significant negative effect on the mental health of healthcare personnel as a result of the limited, uncooperative, and life-threatening labor in the confined covid-19 environment. working shorter shifts and adjusting them can help improve healthcare workers' cope with crises and ensure worker safety. to prevent mental health issues in the future, workers' trauma and experiences should be kept to a minimum [12]. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator garcia, et al. covid-19 and mental health of healthcare workers https://doi.org/10.47488/dhrp.v2is2.51 dhr proceedings ǀ http://dhrproceedings.org 22 2022, vol. 2 no. s2 20-22 funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. şahin, m. k., aker, s., şahin, g., & karabekiroğlu, a. (2020). prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during covid-19 pandemic in turkey. journal of community health, 45(6), 1168– 1177. https://doi.org/10.1007/s10900-02000921-w. 2. elizabeth. “what is a healthcare provider?” verywell health, verywell health, 23 mar. 2014. 3. muller ae, hafstad ev, himmels jpw, smedslund g, flottorp s, stensland sø, stroobants s, van de velde s, vist ge. the mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: a rapid systematic review. psychiatry res. 2020 nov; 293:113441. do i: 10.1016/j.psychres.2020.113441. epub 2020 sep 1. pmid: 32898840; pmcid: pmc7462563. 4. blake, h., bermingham, f., johnson, g., & tabner, a. (2020). mitigating the psychological impact of covid-19 on healthcare workers: a digital learning package. international journal of environmental research and public health, 17(9), 2997. https://doi.org/10.3390/ijerph17092997. 5. galanis, p., vraka, i., fragkou, d., bilali, a., & kaitelidou, d. (2021). nurses' burnout and associated risk factors during the covid-19 pandemic: a systematic review and metaanalysis. journal of advanced nursing, 77(8), 3286–3302. 6. blake h, bermingham f, johnson g, tabner a. mitigating the psychological impact of covid-19 on healthcare workers: a digital learning package. int j environ res public health. 2020 apr 26;17(9):2997. doi: 10.3390/ijerph17092997. pmid: 32357424; pmcid: pmc7246821. 7. shoja, e., aghamohammadi, v., bazyar, h., moghaddam, h. r., nasiri, k., dashti, m., choupani, a., garaee, m., aliasgharzadeh, s., & asgari, a. (2020). covid-19 effects on the workload of iranian healthcare workers. bmc public health, 20(1), 1636. 8. krause m, henderson a, griner d, rissland os, beard j, bartels k. a statewide voluntary movement addressing the shortage of medical supplies during the covid-19 pandemic. am j public health. 2021 sep;111(9):1595-1599. doi: 10.2105/ajph.2021.306364. epub 2021 aug 26. pmid: 34436929; pmcid: pmc8589063. 9. “covid-related nursing shortages hit hospitals nationwide | cidrap.” cidrap, https://www.cidrap.umn.edu/newsperspective/2020/11/covid-related-nursingshortages-hit-hospitals-nationwide. accessed 17 june 2022. 10. “nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care pmc.” pubmed central (pmc), https://www.ncbi.nlm.nih.gov/pmc/articles/p mc3201822/. accessed 17 june 2022. 11. “ethical challenges of nurses in covid-19 pandemic: integrative review pmc.” pubmed central (pmc), https://www.ncbi.nlm.nih.gov/pmc/articles/p mc8110276/. accessed 17 june 2022. 12. spoorthy, m. s., pratapa, s. k., & mahant, s. (2020). mental health problems faced by healthcare workers due to the covid-19 pandemic-a review. asian journal of psychiatry, 51, 102119. https://doi.org/10.1016/j.ajp.2020.102119. 2021, vol. 1 (2) 3-4 https://doi.org/10.47488/dhrp.v1i2.6 http://dhrproceedings.org 3 © dhr health institute for research and development trauma bulletin critical care in the air – when seconds matter airmed south texas jonathan allua 1 1 ems operations, hidalgo county ems, and airmed south texas, edinburg, texas, usa e-mail: jallua@hidalgocountyems.org received 12/17/2020 accepted for publication 01/08/2021 published 03/05/2021 keywords: trauma; injury; emergency; helicopter; critical care there are a “few” adages in emergency medicine, “time is muscle” referring to a heart attack, “time is brain” referring to a stroke, and the pinnacle, “the golden hour” referring to a trauma patient, and the importance of reaching a trauma facility within the first hour from injury. what do they all have in common? they all specify that time is of the essence. airmed 1 is a medical helicopter serving the rio grande valley (rgv; figure 1). cruising at 155mph, airmed 1 can rendezvous with ems units and transport to the hospital in a fraction of the time it would take by ambulance. for example, traveling from edcouch to dhr health by ambulance takes an estimated 30 minutes. airmed 1 can make the trip in only 6 minutes. the same is true for most of the region where the helicopter can transport to the tertiary care center more rapidly compared to ambulance transport saving valuable minutes that could impact a patient’s clinical outcome. airmed 1 is not only a fast ride, but it is also the biggest benefit bringing the critical care transport team directly to the patient. staffed with a critical care transport nurse and critical care transport paramedic, the team brings an advanced level of knowledge, training, and equipment to complement the care being provided by the ems crew. for example, blood loss is one of the biggest threats to a trauma patient in the field. to combat this, airmed 1 carries whole blood and liquid plasma on every flight. the ability to replace blood loss with whole blood rather than just iv fluids alone significantly increases a patient’s chances of survival.airmed 1 also transports patients from one facility to another. often, patients are diagnosed with a life-threatening condition requiring specialized care that is provided at another facility. this results in an interfacility transfer. the critical care transport team has the capabilities and equipment required to continue the level of care initiated at the sending facility while simultaneously initiating care that will be provided at the receiving facility. airmed 1 is a valuable resource available to the entire rgv. our mission is to provide the residents and visitors of the region with the highest quality and most advanced clinical care available. our goal is to be a partner with every ems, fire department, law enforcement agency, and healthcare facility in the region to assist with the care and transport of your most critical patients. figure 1: a picture of airmed helicopter landing in a helipad near one of the hospitals in the rgv. critical care in the air 2021, vol. 1 (2) 3-4 http://dhrproceedings.org 4 © dhr health institute for research and development diclosures author’s professional qualifications: rn, lp, ccrn, cfrn, cmte. ja is the chief of ems operations and chief flight nurse for hidalgo county ems & airmed south texas. references no references were used in this document. 2021, vol. 1 (s4) 6-8 https://doi.org/10.47488/dhrp.v1is4.20 http://dhrproceedings.org 6 © dhr health institute for research and development commentary an evolving public health crisis caused by the rapid spread of the sars-cov-2 delta variant the protective effect of vaccination sohail rao, md, ma, dphil1, 2 and manish singh, md, facs3 1 executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas 78539 and president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0001-5027-9992 2 correspondence should be addressed to: sohail rao, md, ma, dphil., dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. tel: (956) 362-2387. e-mail: s.rao@dhr-rgv.com 3 chief executive officer, dhr health, 5501 s. mccoll road, edinburg tx 78539 and dhr health bariatric and metabolic institute, 500 raphael drive, edinburg, tx 78539 orcid: manish singh: https://orcid.org/0000-0003-4146-3282 received 06/24/2021 accepted for publication 06/29/2021 published 06/29/2021 keywords: covid-19; sars-cov-2; delta virus; vaccination sars-cov-2 virus has already infected over 181 million people worldwide and has resulted in the death of over 3.9 million (1). in the united states alone, over 33 million people have been infected with sars-cov-2 which has resulted in the death of over 600,000 (1). the rapid development and deployment of several effective vaccines against the virus has lowered but not eliminated the threat to imminent public health crisis. further compounding this challenge is the continued vaccine hesitancy and the non-availability of vaccines globally (2). the notable competence of viruses to adapt to new hosts and environments is largely conditional on their capacity to generate de novo multiplicity in a relatively short period of time (3). it is therefore predictable that the rates of spontaneous mutation would vary among viruses. additionally, rna viruses mutate at a much faster rate than dna viruses and the size of the genome is conversely related to the rate of mutation. it is important to note that selective host and environmental pressures (such as the use of anti-viral agents, etc.) can impact the rate of viral mutation thus accelerating the generation of new and more contagious variants (4).sars-cov-2 is an rna virus and under optimal conditions it has a very high rate of mutation. the centers for disease control and prevention has developed a variant classification scheme that defines three classes of sars-cov2 variants (5). to date, none of the sars-cov-2 variants has been identified as a variant of high consequence. on the contrary, seven variant of interest and six variant of concern have been identified (5). most of the variants have mutations in the gene encoding sars-cov-2 spike protein, which affects their transmissibility; disease severity; reduced neutralization by antibodies generated against previous infection or vaccination; reduced efficacy of available treatment; and potential diagnostic impact. one of the variants of sars-cov-2 that is a variant of concern and is rapidly spreading in the us is of the lineage b.1.617.2 (figure 1). erroneously labelled as the “indian variant”, this mutant was first reported in india, but its true origin remains unknown (6). renamed as the delta variant by the world health organization, it is believed to be the cause of the devastating second wave of the pandemic in india, which crippled its healthcare infrastructure resulting in thousands of deaths everyday (7, 8). also identified as the variant of global concern, b.1.717.2 has been detected in more than 40 countries and is the dominant variant in the united kingdom (9). the delta variant has mutations in the gene encoding the spike protein causing substitutions t478k, p681r and 452r (10). collectively, these mutations increase https://orcid.org/0000-0001-5027-9992 mailto:s.rao@dhr-rgv.com https://orcid.org/0000-0003-4146-3282 dhrp, 2021, vol. 1 (s4) 6-8 the protective effect of vaccination http://dhrproceedings.org 7 © dhr health institute for research and development viral transmissibility and alter the neutralizing ability of monoclonal antibodies and convalescent plasma from recovered patients with covid-19. figure 1: the percentage of delta variants in patients diagnosed with sars-cov-2 in the us. a recent study published in the journal lancet suggested that the risk of hospitalization doubled in those infected with the delta variant of sars-cov-2 as compared to the alpha variant (11). additionally, this study also underscored the protective effect of vaccination against infection with this variant. pfizer-biontech vaccine was 88% effective against symptomatic disease from the b.1.617.2 variant two weeks after the second dose. two doses of the astrazeneca vaccine were 60% effective against symptomatic disease from the b.1.617.2 variant. it is notable that both vaccines were only 33% effective against symptomatic disease from delta variant, three weeks after the first dose (11). given these observations, it can be envisaged that as in the past, sars-cov-2 virus will continue to mutate, and it is likely that future variants will be as infectious if not more than the currently circulating mutants. therefore, it is imperative that we intensify our efforts to sequence all positive cases of covid-19 to ascertain the extent of sars-cov-2 mutations. lastly, given the protective effect of currently available vaccines, it is highly recommended that all qualified individuals 12 years and above get vaccinated to protect themselves from symptomatic disease resulting from exposure to either the wild-type and/or the variants of sars-cov-2 virus. incentivizing qualified individuals should be seriously considered particularly in regions of relatively lower vaccination rates and younger adults who are seemingly hesitant to get vaccinated. needless to say, a robust and sustained public health education program is essential to address existing crisis and to mitigate such challenges in the future. diclosures sr declares no conflicts of interest. ms declares no conflicts of interest. funding the project is funded by a seed grant from the dhr health institute for research & development references 1. covid-19 dashboard – johns hopkins university coronavirus resource center. june https://coronavirus.jhu.edu/map.html (assessed jun 28, 2021: 8:21 a.m. est) 2. killgore wds., cloonan sa, et al. the covid-19 vaccine is here – now who is willing to get it? vaccines (basel). 2021 apr 1;9(4):339. doi: 10.3390/vaccines9040339. pmid: 33916161 3. regoes rr., hamblin s and tanaka mm. viral mutation rates: modelling the roles of within-host viral dynamics and the trade-off between replication fidelity and speed. proc biol sci. 2013 jan 7;280(1750):20122047. doi: 10.1098/rspb.2012.2047. epub 2012 nov 7. 4. domingo e and holland jj. rna virus mutations and fitness for survival. annu rev microbiol. 1997;51:15178. doi: 10.1146/annurev.micro.51.1.151. 5. sars-cov-2 variant classifications and definitions. https://www.cdc.gov/coronavirus/2019ncov/variants/variant-info.html#interest. (assessed jun 23, 2021) 6. cherian s., agarwal a., et.al. convergent evolution of sars-cov-2 spike mutations, l452r, e48q and p681r, in the second wave of covid-19 in maharashtra, india. available online: https://www.biorxiv.org/content/10.1101/2021.04.22.44 0932v1 (assessed jun 23, 2021) 7. branswell h. the name game for coronavirus variants just got easier. https://www.statnews.com/2021/05/31/the-name-gamefor-coronavirus-variants-just-got-a-little-easier/ (assessed jun 23, 2021) 8. mudur gs. covid: second wave threatens to sink healthcare services. https://www.telegraphindia.com/india/second-wavethreatens-to-sink-healthcare-services-impact-of-covidbegins-to-tell-on-three-worst-affectedstates/cid/1812271 (assessed jun 23, 2021) 9. delta variant causes more than 90% of new covid cases in uk. https://www.theguardian.com/world/2021/jun/11/deltavariant-is-linked-to-90-of-covid-cases-in-uk (assessed jun 23, 2021) https://coronavirus.jhu.edu/map.html https://www.cdc.gov/coronavirus/2019-ncov/variants/variant-info.html#interest https://www.cdc.gov/coronavirus/2019-ncov/variants/variant-info.html#interest https://www.biorxiv.org/content/10.1101/2021.04.22.440932v1 https://www.biorxiv.org/content/10.1101/2021.04.22.440932v1 https://www.statnews.com/2021/05/31/the-name-game-for-coronavirus-variants-just-got-a-little-easier/ https://www.statnews.com/2021/05/31/the-name-game-for-coronavirus-variants-just-got-a-little-easier/ https://www.telegraphindia.com/india/second-wave-threatens-to-sink-healthcare-services-impact-of-covid-begins-to-tell-on-three-worst-affected-states/cid/1812271 https://www.telegraphindia.com/india/second-wave-threatens-to-sink-healthcare-services-impact-of-covid-begins-to-tell-on-three-worst-affected-states/cid/1812271 https://www.telegraphindia.com/india/second-wave-threatens-to-sink-healthcare-services-impact-of-covid-begins-to-tell-on-three-worst-affected-states/cid/1812271 https://www.telegraphindia.com/india/second-wave-threatens-to-sink-healthcare-services-impact-of-covid-begins-to-tell-on-three-worst-affected-states/cid/1812271 https://www.theguardian.com/world/2021/jun/11/delta-variant-is-linked-to-90-of-covid-cases-in-uk https://www.theguardian.com/world/2021/jun/11/delta-variant-is-linked-to-90-of-covid-cases-in-uk dhrp, 2021, vol. 1 (s4) 6-8 the protective effect of vaccination http://dhrproceedings.org 8 © dhr health institute for research and development 10. "expert reaction to vui-21apr-02/b.1.617.2 being classified by phe as a variant of concern". sciencemediacentre.org. may 07, 2021. (assessed jun 23, 2021) 11. sheikh a., mcmenamin j., taylor b., robertson c., on behalf of public health scotland and the eave ii collaborators. sars-cov-2 delta voc in scotland: demographics, risk of hospital admission, and vaccine effectiveness. the lancet. june 14, 2021. https://doi.org/10.1016/s0140-6736(21)01358-1 https://doi.org/10.1016/s0140-6736(21)01358-1 2021, vol. 1 (2) 1-2 https://doi.org/10.47488/dhrp.v1i2.4 http://dhrproceedings.org 1 © dhr health institute for research and development trauma bulletin a christmas story jeffrey j. skubic1,2 1 trauma medical director, dhr health, edinburg, tx, usa 2 assistant professor of surgery, the university of texas at rio grande valley school of medicine, edinburg, tx, usa e-mail: j.skubic@dhr-rgv.com received 12/03/2020 accepted for publication 01/28/2021 published 03/05/2021 keywords: trauma; injury; emergency; surgery; it is christmas night at your house at 2100 hours. everyone is all sitting around the house lounging, enjoying themselves after a long well deserved christmas feast. giggling erupts from the living room, where all the children of the extended family are watching holiday cartoons. frank sinatra sings for his supper on the radio in the distant kitchen, while a large crackle erupts from the beautifully cut logs in the fireplace. suddenly there is a loud boom, boom, and thud. the crash is heard from the front stairwell. after quickly placing your glass of port down, you rush to the front of the house only to find your beloved 80-year-old uncle on the hardwood floor face down. after you carefully roll him over, you note a swollen right face and very deformed nose. your astutely peel open his right eye and note that he does not have full motion of his right eye. feeling the effects of the alcohol, you ask your brother, who does not drink, to drive both of you to the hospital immediately. you assist your uncle to the car and have him hold an ice pack to his face the entire ride. at the hospital emergency room (er), the emergency physician and trauma surgeon on call examine your uncle. after examining him and performing a ct they share the news that your uncle has a severely deformed nasal fracture, a severe right orbital fracture, and real concern for nerve entrapment. he also has a small subdural hematoma that needs to be watched. the trauma surgeon then shares the dreaded news with you: there are no appropriate surgeons on call that night; they are going to prepare to transfer your uncle 250 miles to san antonio, where the appropriate trauma team and surgeons will be waiting to receive him. you, as a healthcare worker, will you demand that they keep your uncle here? will you stamp your feet and demand they call each surgeon and find someone willing to come in? will you call the physician administrator on-call, complain that this is unacceptable, and demand they find a surgeon? will you, yourself, retrieve your cell phone from your jacket and call your colleagues demanding that one of them come to the hospital immediately to operate on your family member. despite trying all, your uncle is loaded on a helicopter and is gone. you share your frustration with your family. unfortunately, we and many others are faced with this awkward scenario. but why should this occur in 2020 in one of the more advanced countries in the world? the answer lies in an understanding that trauma is a disease, and the trauma patient requires the appropriate care from the appropriate facility as quickly as possible to treat their disease. that is the case for myocardial infarction and a cerebral bleed. the same is true for the trauma victim; why should they be treated any less? for this to occur, we need to have the level of care near the trauma patient with the resources to care for the victim 24/7 completely. trauma, like all other diseases, knows no limits! your family asks you, “what should our uncle really get?” “he needs a ‘level one’ here!” “a what?” they ask. “a level one trauma center. let me explain:” trauma centers in the united states are identified in two fashions: a designation process and a verification process. the different levels (i.e. level i, ii, iii, iv or v) refer to the resources available in a trauma center and the number of patients admitted yearly. these are categories defined by national standards for trauma care in hospitals. the categorization area is also unique to both adult and pediatric a christmas story 2020, vol. 1 (2) 1-2 http://dhrproceedings.org 2 © dhr health institute for research and development facilities. the trauma center designation is a process outlined and developed at a state or local level. the state or local municipality identifies unique criteria in which to categorize trauma centers. these categories vary from state to state and are typically outlined through legislative or regulatory authority. trauma center verification is an evaluation process done by the american college of surgeons (acs) to evaluate and improve trauma care. the acs does not designate trauma centers; instead, it verifies the presence of the resources listed in resources for optimal care of the injured patient. these include commitment, readiness, resources, policies, patient care, performance improvement, education, and research. verification is a voluntary process by the trauma center, and if verified, it lasts for a 3-year period. let me outline the common criteria for a level one trauma center as verified by the acs and also designated by states. level i trauma center is a comprehensive regional resource that is a tertiary care facility central to a trauma system. a level i trauma center is capable of providing total care for every aspect of injury – from prevention of the injuries through to the rehabilitation. in fact, rehabilitation is the key to the victim making a complete recovery. the key resources of a level i trauma centers include 24-hour in-house coverage by trauma (general) surgeons and prompt availability of care in specialties such as orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial, hand surgery, cardiac surgery, thoracic surgery, vascular surgery, obstetrics and gynecology, ophthalmology, urology and critical care. they are a referral resource for communities in nearby regions. they provide leadership in the prevention, public education to surrounding communities, and continuing education to their trauma team members. level one trauma centers incorporate a comprehensive quality assessment program to keep their trauma care at a high level of performance. they provide organized teaching and research effort to help direct new innovations in trauma care particularly unique to the community they serve. importantly they have programs for substance abuse screening and patient intervention. finally, they need to meet a minimum requirement for the annual volume of severely injured patients to keep their trauma team experienced and always ready. in our uncle's case, he is best served in such a center with all the resources listed above available to him. he has multiple injuries and an ongoing injury of concern. he will require surgery and maybe even a second surgery. then he will need post-operative care and rehabilitation to get him back to his quality of life. he needs an experienced team that can provide his trauma care immediately and not far from his home. sadly we don’t have that here. so why should anyone not be provided with that level of care? as the new year comes, let us continue to push to have a level one trauma center in the rio grande valley. let us not have to repeat this christmas story. in the new year let us treat our trauma victims the way they should be, and here at home. diclosures jjs declares no conflicts of interest. references no references used in this document. special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.58 dhr proceedings ǀ http://dhrproceedings.org 72 2022, vol. 2 no. s2 72-77 commentary bacteriophage therapy: an alternative solution for antibiotics mandy pina1,2, angela salinas1,3, layla arellano1,5, srinidhi sompalli1,4, valeria trevino1,3, elanie castillo1,3, molisha lopez1,3, april pena1,3 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2idea san juan college preparatory, san juan, tx 3grulla high school, rio grande city, tx 4lamar academy/ mcallen memorial high school, mcallen, tx 5harlingen school of health professions, harlingen, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/01/2022 accepted for publication 08/05/2022 published 08/05/2022 keywords: bacteriophages; phage therapy; virus; antibiotics, super bacteria; introduction for the past 100 years, bacteriophage, or phage therapy, has greatly helped close the gap of resistance to antibiotics. this has been a great compliment to antibiotics and is slowly becoming an alternative to antibiotics. it was originally discovered in 1915 by federick twort and felix d’herelle in great britain, which started the beginning of molecular biology (1). d’herelle coined the term bacteriophage meaning “bacteria eater” to describe the agent’s bactericidal ability (2). phage therapy goes way back to the times of world war ii, when armies from germany and japan would practice phage therapy in their medical services to soldiers, and even today bacteriophage therapy still persists (3). bacteriophages work by killing bacteria and create a form of therapy that regulates itself at the sites of the infection and decays once the bacteria is completely killed (4). the use of phages has been proposed since its inception as a therapy to treat acute and chronic infections with initial successes first described in the disciplines of dermatology, ophthalmology, urology, stomatology, pediatrics, otolaryngology, and surgery (3). according to the united kingdom government’s 2016 review on antimicrobial resistance, an estimated 700,000 people die each year globally from resistant infections with a projected cost of $100 trillion and a death toll of 10 million by 2050 (5). bacteriophage endolysins, enzymes that degrade the bacterial peptidoglycan (pg), have gained an increasing interest as alternative agents, due to their ability to kill antibiotic resistant pathogens efficiently when applied externally as purified proteins (6). they are ubiquitous in the environment and are recognized as the most abundant biological agent on earth. they are extremely diverse in size, morphology, and genomic organization (7). in this review, the information below will serve to explain the concept of phage therapy, from the pros and cons of phage therapy to the amount of availability that bacteriophage therapy can reach. what is a bacteriophage? bacteriophages, also referred to as phages or bacteria viruses are any type of viruses that infect bacteria. like many viruses, phages are simple pina, et al. bacteriophage therapy https://doi.org/10.47488/dhrp.v2is2.58 dhr proceedings ǀ http://dhrproceedings.org 73 2022, vol. 2 no. s2 72-77 organisms that have a core of nucleic acid surrounded by a protein capsid. phages are classified in a variety of virus families, which include: inoviridae, microviridae, rudivirade, and tectiviridae (8). the nucleic acid that surrounds the core consists of dna or rna and can be double stranded or single stranded. bacteriophage has three basic structural forms such as an icosahedral head with a tail, and a flamentus form (see figure 1). in the process of an infection, a phage attaches to a bacterium and inserts its genetic material into the cell. furthermore, a phage usually follows one of two life cycles, which is either lytic (virulent) or lysogenic (temperate) bacteriophage (8). the lysogenic cycle is when the dna is only replicated, not transformed into proteins. the lytic cycle is when a virus hijacks a host cell, uses its components to make more of the virus, and then destroys and exits the cell and continues to infect other cells bacteriophage (8). under certain circumstances, lysogenic phages can be induced to follow a lytic cycle. understanding the structure of a bacteriophage allows us as researchers to make better decisions when it comes to treatment as well as understand how it reacts with the patient's body (9). figure 1 why do we need bacteriophages? the need for bacteriophages, or an alternative medication for antibiotics, has been increasing, and although research on them has been going on for the past 100 years, the reliance on antibiotics has sabotaged further research on the topic (10). with the reintroduction, launched in early 2011 by alexander sulakvelidze, he released the new bacteriophage journal where he discusses bacteriophages and how “they play a significant role in maintaining the microbial balance of the planet.” from this came a new spark in the research of these phages, and a resurgence in the practical use of these medications (3). first, we need these viruses to combat bacteria because of a process known as the antibiotic treadmill or resistance treadmill. this is the process of bacteria becoming resistant to most types of antibiotics after their usage because of mutations. strains of bacteria adapt to become resistant towards different types of antibiotics resulting in increased dosages, using multiple antibiotics, and overall, not being able to efficiently treat bacterial infections. secondly, many of these strains have a pattern of arising in nosocomial disease, a disease that is contracted from the hospital. this means that patients who are already being treated for a disease could be contracting potentially a strain of bacteria that is highly resistant to antibiotics which causes a decrease in their chances of survival. one example of this is with a critically ill patient with a multidrugresistant bacteria acinetobacter baumannii infection, who was also combatting covid-19 at the time. (11) this patient essentially had a slim to none chance of survival and his condition worsened even with the antibiotics that the bacteria strain seemed susceptible to. however, through bacteriophage therapy the patient’s condition improved greatly and he made a recovery (11). therefore, because of the effectiveness of this treatment, there needs to be more access to this treatment and more rigorous clinical trials in order to get this therapy available for widespread use across texas and the rio grande valley. the process of bacteriophage therapy as before mentioned, a large reason bacteriophage are needed is because of a process known as the resistance treadmill. approximately 100 years ago, antibiotics became the gold standard for treating bacterial infections. however, a new crisis has occurred where bacteria have become highly resistant to multiple antibiotic treatments, and not all antibiotics react well to everyone’s body (7). because of this we need to outpace the bacteria to solve the antibiotic resistance crisis. the rapid increase in amrb (antimicrobial resistance bacteria) led researchers to look for alternative treatments, and currently one of the most promising ones are bacteriophages. current research is being done on the use of phages and lytic proteins, mainly against drug resistant bacterial infections, and potentially as an alternative for antibiotic treatments (14). the reason bacteriophages are more efficient than antibiotics is because super bacteria have yet to become resistant to bacteriophages. there are also many more advantages to bacteriophages over antibiotics, such as the high therapeutic index and having fewer side effects, and their specialty and other safety for the host organism, including the intestinal microbiota (14). pina, et al. bacteriophage therapy https://doi.org/10.47488/dhrp.v2is2.58 dhr proceedings ǀ http://dhrproceedings.org 74 2022, vol. 2 no. s2 72-77 to put it simply, bacteriophages are the predators for bacteria. while this seems very broad, that is what they do. whether it is a urinary tract infection, or a strain of e. coli, phage therapy has been proven to effectively treat these infections with no major side effects reported (12). although there are yet to be more rigorous clinical trials on the treatment, there are many benefits to be considered. there are different routes of administration depending on the area of infection on the human body. one option is oral treatment that can be given three times a day. this is done by first neutralizing the gastric acid so the phages can thrive and spread, achieved by giving the patient sodium bicarbonate or bicarbonate mineral water (baking soda) (12). the second way it is administered is locally by applying a moist bandage with the phages onto an open wound to allow the phages to enter the body (12). it can also be administered using drops on the eyes, or in the mucous membrane, through intravenous drip, or by nebulization (12). the goal of all of these methods is to allow the phages to enter the body without being destroyed by our body's defenses, stomach acid, the skin, and our eyelashes/ nose hairs (12). by doing this the phages are allowed to safely enter the body and kill the strains of bacteria causing the infection. once inside the body, the bacteriophages work through a process named lysis. the virus infiltrates the bacteria’s cell membrane by injecting its own dna and rna. it then creates up to 1,000 copies of itself and causes the bacteria to lyse or burst (1). then, once the bacteria is gone it will stop multiplying and remain dormant until more bacteria enters the body. furthermore, the phages will not attack human cells because they have high specificity, meaning they only attack the bacteria (13). the therapy lasts about 1-16 weeks and is highly effective. overall, the process of bacteriophage therapy is very simple and takes a short time period with mild side effects reported. advantages on bacteriophage therapy the use of bacteriophages as antimicrobial agents is one possible replacement option for antibiotics (15). lytic bacteriophages are able to kill antibiotic-resistant bacteria at the end of the phage infection cycle. thus, the development of phage therapy is potentially a way to improve the treatment of bacterial infections (16). while not common in south texas, but talked about for future resources, phage therapy is an important alternative to antibiotics in the current era of drug-resistant pathogens. another reason this type of therapy is beneficial is because these phages cannot infect human cells (17). phage therapy is a natural and secure form of antibiotics working to treat infections and to use the bacteria to replicate themselves which results in a cycle of killing bacteria while also producing more copies to keep destroying. because of these bactericidal agents, bacteria get infected and do not regain their viability, meaning once it is killed it remains dead whilst other antibiotics are bacteriostatic, meaning they only stop the growth of bacteria contributing further to its resistance. another advantage is the auto “dosing” factor of bacteriophages, it has been proven to reproduce in areas where the host is located making them even more effective in curing an infection (17). some other advantages include non-toxicity, phages are made of proteins and nucleic acids that are nontoxic (something a lot of antibiotics cannot claim), and although they can cause harmful responses from the immune system, they can be prevented by using purified phage preparations to prevent anaphylactic reactions (the immune system releases a flood of chemicals resulting in the body going into shock) (17). minimal shock to normal flora, unlike most antibiotics that are broad spectrum, bacteriophages do not harm the microbiome that is found inside of our bodies whilst antibiotics tend to harm or kill the “good” bacteria within us that maintain balance. lack of cross resistance, since super bacteria only have resistance mechanisms made for antibiotics, the difference of the attack system of phages allows the phages to kill these types of bacteria more effectively, (think of it as a surprise attack). bacteriophage may have single dose potential, because of their auto-dosing, there is potential for the phages to be applied only once and allow them to multiply and kill. although culturing the bacteria can be expensive for testing, phage purification prices are declining due to improvements in the technology and compared to prices of pharmaceuticals is relatively low (17). disadvantages of bacteriophage therapy concerns about using phages as antibacterial agents can be distinguished into four categories: (1) phage selection, (2) phage host-range limitations, (3) the “uniqueness” of phages as pharmaceuticals, and (4) unfamiliarity with phages (17). when dealing with bacteriophage therapy, one of the most common disadvantages is that researchers must choose one specific phage and weigh whether the benefits of phage therapy outweigh the risks. each bacteriophage is unique in its own way which could be a disadvantage because it is harder to have concrete research on each of them. the most common and also biggest disadvantage is the limited knowledge about the effectiveness of phage therapy. having limited pina, et al. bacteriophage therapy https://doi.org/10.47488/dhrp.v2is2.58 dhr proceedings ǀ http://dhrproceedings.org 75 2022, vol. 2 no. s2 72-77 information makes it harder to do research and have a positive outcome when it comes to experimenting with phages, and phage therapy. and even though it is classified as gras (generally regarded as safe) by the fda, the general public regards these phages as equivalent to an antigen (an organism that causes disease) instead of as a cure. however, so far people have not been resistant to this treatment because it is known as a “phage” rather than a virus. some other disadvantages to consider, these are live organisms that can trigger the human immune system to respond and can carry endotoxins, which are normally cleared in the phage preparation stage. there is also a narrow host range, or only a small range of bacteria can be targeted by phages, however this can be solved by mixing phages (otherwise known as phage cocktails) and can create a broader spectrum for this therapy (17). availability of bacteriophage therapy recent studies of bacteriophage therapy have been successful, which helps increase the probability of the therapy to become more common in all regions. as phage therapy is considered safe, this leads to possible use in the future for patients who have drug resistant infections. one reason why phage therapy hasn't been approved yet is because antibiotics prescribed are more available to the public and are considered to be safer by the fda. currently there is ongoing research on the best way to use phages and phage therapy on pathogens, and how to make it more available to the public in the near future. since phage therapy has not been approved in the us or europe, there have only been rare cases where it was used. our hope is that more research and more trials can be done on this topic to make the treatment more available to the public. one such study was performed at dhr health in 2021 (11). while not commonly heard of in the rio grande valley, there have been a few exceptional cases in which bacteriophage therapy was used experimentally. currently, there is not a standard of care regimen for phage therapy as it is still in the experimental phase. some research indicates about 116 weeks for the therapy, and because of auto-dosing, a single dose can be effective enough to treat the whole infection (13, 17). phages are currently undergoing study and experimental use for future and safer use on humans. target age groups when working with bacteriophage therapy target age groups are not specified. it has been experimented on people of all different ages who have the issue of not being able to intake antibiotics. any person who is not able to utilize antibiotics because they have no function on them are considered for this experimental phase. they are known to be used for people of all ages above five to fight off multidrug resistant bacteria (18). conclusion this treatment would benefit rgv patients in several ways. one reason is that using bacteriophage therapy has no major side effects. secondly, it can be administered in several ways such as eye drops, in the mucous membrane, applied locally to an open wound, can be given intravenously or even through nebulization. antibiotics can be replaced with the use of bacteriophages as antimicrobial agents. using a bacteriophage is a way to end the infection cycle, and as mentioned earlier, it is a safer method to eliminate drug resistant pathogens. bacteriophages, being a natural bacteria predator, have become a greatly used alternative or even a supplement to reduce the need for antibiotics because bacteria can develop resistance to conventional antibiotics. in general, it can be said that phage therapy, long overshadowed by chemical antibiotics, is gathering renewed interest in western medicine. this stems from the rise in frequency of multidrug-resistant bacterial infections in humans (19). according to lin et al., “the available literature on the use of phages and phage-derived proteins for combating bacterial infections, specifically those of multidrug-resistant bacteria, increasingly shows promise for the prospect of phage therapy as either an alternative or a supplement to antibiotics'' (5). bacteriophage therapy is an opportunity to help cure patients in the rgv with multi-drug resistant infections. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator pina, et al. bacteriophage therapy https://doi.org/10.47488/dhrp.v2is2.58 dhr proceedings ǀ http://dhrproceedings.org 76 2022, vol. 2 no. s2 72-77 funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. taylor mw. introduction: a short history of virology. viruses and man: a history of interactions. 2014 jul 22:1–22. doi: 10.1007/978-3-319-07758-1_1. pmcid: pmc7123787. 2. the editors of encyclopedia britannica. (2018). bacteriophage | definition, life cycle, & research. in encyclopædia britannica. https://www.britannica.com/science/bacterio phage 3. wittebole, x., de roock, s., & opal, s. m. (2014). a historical overview of bacteriophage therapy as an alternative to antibiotics for the treatment of bacterial pathogens. virulence, 5(1), 226–235. https://doi.org/10.4161/viru.25991 4. rohde, c., wittmann, j., & kutter, e. (2018). bacteriophages: a therapy concept against multi-drug-resistant bacteria. surgical infections, 19(8), 737–744. https://doi.org/10.1089/sur.2018.184 5. lin, d. m., koskella, b., & lin, h. c. (2017). phage therapy: an alternative to antibiotics in the age of multidrug resistance. world journal of gastrointestinal pharmacology and therapeutics, 8(3), 162–173. https://doi.org/10.4292/wjgpt.v8.i3.162 6. shang x, nelson dc. contributions of net charge on the plyc endolysin chap domain. antibiotics (basel). 2019 may 28;8(2):70. doi: 10.3390/antibiotics8020070. pmid: 31142020; pmcid: pmc6628322. 7. (kasman lm, porter ld. bacteriophages. [updated 2020 oct 1]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2020 jan-. available from:yap, moh lan, and michael g rossmann. “structure and function of bacteriophage t4.” future microbiology vol. 9,12 (2014): 1319-27. doi:10.2217/fmb.14.91)(weigel c, seitz h. bacteriophage replication modules. fems microbiol rev. 2006 may;30(3):32181. doi: 10.1111/j.1574-6976.2006.00015.x. pmid: 16594962.)(howard-varona, cristina et al. “lysogeny in nature: mechanisms, impact and ecology of temperate phages.” the isme journal vol. 11,7 (2017): 15111520. doi:10.1038/ismej.2017.16) 8. bacteriophagedefinition, structure, life cycles, applications, phage therapy (microbenotes.com) 9. (britannica, t. editors of encyclopedia (2018, october 12). bacteriophage. encyclopedia britannica. https://www.britannica.com/science/bacterio phage) bacteriophage | definition, life cycle, & research | britannica 10. ibrahim s, al-saryi n, al-kadmy ims, aziz sn. multidrug-resistant acinetobacter baumannii as an emerging concern in hospitals. mol biol rep. 2021 oct;48(10):6987-6998. doi: 1007/s11033021-06690-6. epub 2021 aug 30. pmid: 34460060; pmcid: pmc8403534. https://phage.health/phage-therapy / 11. rao s, betancourt-garcia m, kare-opaneye yo, świerczewski be, bennett jw, horne b, fackler j, suazo hernandez lp, brownstein mj. critically ill patient with multidrug-resistant acinetobacter baumannii respiratory infection successfully treated with intravenous and nebulized bacteriophage therapy. antimicrob agents chemother. 2022 jan 18;66(1):e0082421. doi: 10.1128/aac.00824-21. epub 2021 oct 18. pmid: 34662188; pmcid: pmc8765271. 12. sulakvelidze, a., alavidze, z., & morris, j. g., jr (2001). bacteriophage therapy. antimicrobial agents and chemotherapy, 45(3), 649–659. https://doi.org/10.1128/aac.45.3.649659.2001 13. iftikhar, n., md. (2019, january 14). what is phage therapy? healthline. 14. (vésale bioscience is a belgian biotech, jehan liénart van lidth de jeude)(díazmuñoz sl, koskella b. bacteriaphage interactions in natural environments.adv appl microbiol. 2014;89:135-83. doi:10.1016/b978-0-12-800259-9.000044.pmid: 25131402.) 15. hyman, p., & abedon, s. t. (2010). bacteriophage host range and bacterial resistance. advances in applied microbiology, 70, 217–248. https://doi.org/10.1089/sur.2018.184 https://doi.org/10.4292/wjgpt.v8.i3.162 https://microbenotes.com/bacteriophage/#:~:text=the%20basic%20structure%20of%20all%20bacteriophages%20is%20the,head%20without%20a%20tail%2c%20and%20a%20filamentous%20form. https://microbenotes.com/bacteriophage/#:~:text=the%20basic%20structure%20of%20all%20bacteriophages%20is%20the,head%20without%20a%20tail%2c%20and%20a%20filamentous%20form. https://microbenotes.com/bacteriophage/#:~:text=the%20basic%20structure%20of%20all%20bacteriophages%20is%20the,head%20without%20a%20tail%2c%20and%20a%20filamentous%20form. https://www.britannica.com/science/bacteriophage https://www.britannica.com/science/bacteriophage https://www.britannica.com/science/bacteriophage https://www.britannica.com/science/bacteriophage https://phage.health/phage-therapy https://doi.org/10.1128/aac.45.3.649-659.2001 https://doi.org/10.1128/aac.45.3.649-659.2001 pina, et al. bacteriophage therapy https://doi.org/10.47488/dhrp.v2is2.58 dhr proceedings ǀ http://dhrproceedings.org 77 2022, vol. 2 no. s2 72-77 https://doi.org/10.1016/s00652164(10)70007-1 16. cisek, a. a., dąbrowska, i., gregorczyk, k. p., & wyżewski, z. (2017). phage therapy in bacterial infections treatment: one hundred years after the discovery of bacteriophages. current microbiology, 74(2), 277–283. https://doi.org/10.1007/s00284-016-1166-x 17. loc-carrillo, c., & abedon, s. t. (2011). pros and cons of phage therapy. bacteriophage, 1(2), 111–114. https://doi.org/10.4161/bact.1.2.14590 18. uc san diego school of medicine. (n.d.). med school.ucsd.edu. retrieved june 29, 2022. from uc san diego school of medicine 19. kortright ke, chan bk, koff jl, turner pe. phage therapy: a renewed approach to combat antibiotic-resistant bacteria. cell host microbe. 2019 feb 13;25(2):219-232. doi: 10.1016/j.chom.2019.01.014. pmid: 30763536. https://doi.org/10.1016/s0065-2164(10)70007-1 https://doi.org/10.1016/s0065-2164(10)70007-1 https://doi.org/10.1007/s00284-016-1166-x https://doi.org/10.4161/bact.1.2.14590 https://medschool.ucsd.edu/ https://medschool.ucsd.edu/ special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.60 dhr proceedings ǀ http://dhrproceedings.org 86 2022, vol. 2 no. s2 86-92 commentary what are the risk factors for alzheimer's disease? brittney benedetti1,2, shiv singh1,3, darlene vargas1,2, leith el-zaim1,4, ashely pruneda1,2, mia padron1,2, nadia ramirez1,5 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2psja memorial high school, alamo, tx 3langley high school, great falls, va 4south texas ish science academy, mercedes, tx 5mcallen high school, mcallen, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/01/2022 accepted for publication 08/05/2022 published 08/05/2022 keywords: alzheimer’s disease; dementia; texas introduction every 68 seconds a person in america is diagnosed with alzheimer’s disease. today, 6 million americans 65 years and older have been affected by alzheimer’s disease; this number is expected to double in the next 30 years (1). alzheimer's disease is now the most common form of neurodegenerative dementia in the united states with a disproportionate disease burden in minority populations. alzheimer’s disease was first discovered by alois alzheimer’s in 1901 when he was treating one of his patients (2). alzheimer's disease is a type of dementia that refers to a particular onset and course of cognitive and functional decline associated with age together with a particular neuropathology. alzheimer's disease is a disorder that causes degeneration of the cells in the brain, and it is the main cause of dementia, which is characterized by a decline in thinking and independence in personal daily activities. ad is considered a multifactorial disease (3). alzheimer's disease care requires timely diagnosis and multidisciplinary management. evaluation involves structured patient and caregiver history and symptomfunction reviews, examination, and testing to delineate impairment level, determine the cognitive-behavioral syndrome, and diagnose cause. additionally, several risk factors such as increasing age, genetic factors, head injuries, vascular diseases, infections, and environmental factors play a role in the disease (4). early reviews identified over 20 risk factors associated with alzheimer's disease including age, familial inheritance, exposure to aluminum, traumatic brain injury and associated co-morbidities such as vascular disease and infection. stages of alzheimer’s alzheimer’s tends to set in during peoples mid-60’s and proceeds to slowly worsen, affecting the memory, processing skills, and overall problemsolving skills of the subject. there isn't a set timeline for alzheimer’s and everyone's experience with the disease is different. alzheimer’s usually progresses in benedetti, et al. alzheimer´s disease https://doi.org/10.47488/dhrp.v2is2.60 dhr proceedings ǀ http://dhrproceedings.org 87 2022, vol. 2 no. s2 86-92 5 distinct stages. stage one is preclinical alzheimer's disease. alzheimer's manifests itself long before any symptoms begin to show and during this stage it is practically impossible to know whether a subject has alzheimer's or not (5). stage 2 would be mild cognitive impairment caused by alzheimer’s. this means that someone at this stage would suffer mild changes in memory and thinking ability. however, it should be noted that mild cognitive impairment (mci) is a byproduct of alzheimer's; not everyone who has alzheimer’s will experience it and not everyone who suffers from it has alzheimer’s (5). the third stage of the disease is mild dementia. this is the stage where alzheimer's is usually diagnosed, because at this stage it becomes fully apparent that the patient is suffering from the symptoms of alzheimer's. some symptoms that people may encounter are changes in personality, memory loss of recent events, difficulty with problem solving, and frequent loss of items of personal value (5). the fourth stage is a progression of the previous stage, with amplified symptoms and a few new ones introduced. during this stage, people experience even more severe personality changes, increased memory loss, and in some cases, even lose the ability to perform everyday tasks without assistance (5). the fifth and final stage of alzheimer's is severe dementia. at this stage, the disease severely affects the mental function of the patient and harshly affects the physical abilities of the patient. once it has progressed this far, the disease renders the patient incapable of doing anything without extensive assistance. the patient would require help with even the most menial of tasks. bathing, clothing, eating, defecating, and in some extreme cases even walking would be beyond the patient's abilities. additionally, the patient also becomes more vulnerable to infections, loses bowel control, bladder control and may even lose the ability to comprehend their surroundings (6). genetics there are genetic risk factors that contribute to why alzheimer’s disease affects many individuals worldwide. according to researchers, approximately 70% of the risk of developing ad can be attributed to genetics (7). as one of the most severe neurodegenerative diseases, alzheimer's disease (ad) is a terrible condition (8). the strongest genetic risk factor for sporadic alzheimer's disease is still the apoe 4 allele. however, there are currently no apoe-specific treatments available (9). the most important genetic risk factor for late-onset ad is the apoe 4 allele, but its specific function in the condition is yet unknown. apolipoprotein e (apoe) is abundantly expressed in the brain and is produced by the apoe gene. there are three different isoforms; the two that affect ad risk are apoe2, which increases risk and apoe3, which is the most common allele in the population. it is strongly contested how apoe affects the development and progression of disease because it has a variety of roles that affect both neuronal and non-neuronal cells (10). presenilin 1 (psen1) was discovered to be an eoad gene with unidentified functions using genetic mapping, gene cloning, and mutation screening of candidate genes. a second presenilin protein, known as presenilin 2, was found in the area connected to ad in a group of families known as volga-german descendants. it was discovered based on protein homology (psen2) (11). as per the alzheimer’s and dementia textbook issue 12 volume 6, researchers have found that early onset alzheimer disease (eoad) has a heritability of between 92 and 100 percent and is nearly entirely genetically based. between 35 and 60 percent of eoad patients have at least one first-degree family who is afflicted, and in 10 to 15 percent of these familial eoad patients, autosomal dominant transmission is the mode of heredity (11). the three eoad genes, which code for the presenilin 1 and 2 (psen1 and psen2) and the amyloid precursor protein (app), were shown to have highpenetrant mutations by genetic analysis of unusually large and informative monogenic pedigrees (11). adults with down syndrome develop the neuropathological hallmarks of alzheimer's disease and are at very high risk of developing early-onset dementia, which is now the leading cause of death in this population (12). diagnosing dementia in patients who have down syndrome is a lot harder than others who do not have the genetic disorder. fluid and imaging biomarkers in those who have down syndrome have shown great diagnostic performances and a strikingly similar being of changes with respect to sporadic and autosomal dominant alzheimer's disease (13). https://doi.org/10.1186/s12929-019-0524-y benedetti, et al. alzheimer´s disease https://doi.org/10.47488/dhrp.v2is2.60 dhr proceedings ǀ http://dhrproceedings.org 88 2022, vol. 2 no. s2 86-92 external and environmental factors it is commonly established and proven that exposure to pollution, intentionally and unintentionally, can cause harmful effects to various parts of the human body. however, some of these negative effects go beyond just lung damage and heart diseases. according to a study in england, 39% of a large number of adults aged 50 to 79 were diagnosed with dementia, 29% with alzheimer’s disease, and 32% with vascular dementia (14). all affected patients were living in an area that contained the highest annual concentration of pollution (14). compared to the other study participants who lived in an area of lower concentration, they were 1.4 times more likely to be diagnosed with those 3 cognitive diseases (14). a prevalent (and intentional) source of bodily harm from toxic pollutants is smoking, which causes a risk of alzheimer's disease and other forms of dementia. a blog from alzheimer’s research uk explains and establishes how the excessive inhalation of tobacco smoke can possibly cause oxidative stress, an imbalance of antioxidants which the body uses to remove toxic molecules. this imbalance damages cells in the brain, resulting in an increased risk of cognitive diseases (15). our dietary lifestyle has major effects on our overall physical and even mental health. a lack of regulation and moderation of the intake of certain foods can cause long-term damaging effects on various parts of the body. according to a usc news article, a diet consisting of foods that are high in fat, sugars, and cholesterol may affect people who carry the apoe4 gene by causing a greater risk of alzheimer’s disease. to prove this statement, researchers from the usc davis school of gerontology presented the results of their experiment involving an unhealthy diet, genes, and their effect on mice. according to the researchers, the mice that carried the alzheimer's related gene were fed an unhealthy diet and were later found to have more signs of brain inflammation, however those with a variant of the gene showed no such signs. this concludes that genetics carry heavy influence over outcome, however, a consistent healthy diet can potentially lower the risk factor for such brain diseases in the future (16). although negative emotions such as stress, anger, and anxiety are often considered to be mere states of mind, they can potentially influence the risk of dementia and related diseases. it has been found that people with alzheimer’s commonly have raised levels of the stress level cortisol, which potentially plays a role in neurodegeneration. patients with alzheimer’s that have consistently high levels of stress are found to have less success when it comes to coping with the pathological changes that are brought on by alzheimer’s disease. it can be established that the best way to reduce this risk factor is to find healthy ways to reduce stress in everyday life. an environment that constantly induces negative emotions can inflict long term negative issues on the brain. a healthy and calm kept mind seems to be the best way to prevent any potential risks or influences of dementia or particularly alzheimer’s disease (17). family history many people affected by dementia are concerned that they may inherit or pass on dementia. people with first-degree family history of alzheimer's disease are at an increased risk of developing dementia by 30% (18). subjective memory impairment among individuals with no measurable cognitive deficits may also indicate elevated dementia risk. the researchers say that it remains unclear whether nondemented people with a positive family history of alzheimer's disease are more likely to experience cognitive deficits and whether such an association reflects underlying neuropathology. they investigated subjective memory impairment in 40 healthy adults and 35 patients with amnestic. (18). this suggests that subjective memory impairment could reflect preclinical stage neurodegeneration among individuals with the family history risk factors (18). the majority of dementia is not inherited by children and grandchildren. in rarer types of dementia, there may be a strong genetic link, but these are only a tiny proportion of overall cases of dementia. according to researchers, a child whose biological mother or father carries a genetic mutation for one of these three genes has a 50/50 chance of inheriting that mutation (19). they say if the mutation is in fact inherited, the child has a very strong probability of developing early-onset alzheimer's disease (19). the researchers suggest that if alzheimer's runs in the family, patients should keep the brain sharp and engage in new learning throughout their lifetime. other ways to prevent getting alzheimer's is eating a brain-healthy diet, preventing head injury, and getting screenings. the researchers say the self-administered gerocognitive exam, known as sage, is a brief pen and paper cognitive assessment tool designed to detect the early signs of cognitive, memory or thinking impairment. the test evaluates your thinking abilities. benedetti, et al. alzheimer´s disease https://doi.org/10.47488/dhrp.v2is2.60 dhr proceedings ǀ http://dhrproceedings.org 89 2022, vol. 2 no. s2 86-92 this can help your doctor understand how well your brain is functioning (20). obesity & diabetes according to researchers, factors such as cerebrovascular diseases (loss of blood flow to the part of the brain, which causes damage to the brain tissue), diabetes (a class of conditions where there is an excess of blood sugar; high blood glucose), & obesity (complex interactions between genetic, socioeconomic, and cultural factors lead to obesity.) increase the risk of alzheimer’s disease development. diabetes and obesity are among the modifiable risk factors for alzheimer's disease. it's interesting to note that new epidemiological studies show that diabetes considerably raises the likelihood of getting alzheimer’s disease, indicating that diabetes may be a causal factor in the pathogenesis of alzheimer's disease. (21). a study observed that obesity is a chronic, multifaceted disorder that affects many different organs and tissues abnormally and has a severe impact on human health. amyloid plaques and neurofibrillary tangles in the brain are connected with alzheimer's disease, a neurodegenerative condition that progresses and cannot be reversed. although there is a link between obesity and alzheimer's disease, the chemicals and molecular mechanisms behind this connection have not yet been fully understood. (22). oxidative stress, mitochondrial dysfunction, and inflammation have all been found to contribute to the neurodegenerative processes seen in these illnesses. researchers discovered critical links between diabetes and alzheimer's disease that are provided by the advanced glycation end products produced by chronic hyperglycemia (posing risk to a variety of cell types and are strongly correlated with the myriad of dmrelated complications, causing long-term complications if untreated). despite being an immuneprivileged organ, the brain has been shown to interact with peripheral and central inflammation. agingrelated damage to the blood brain barrier can cause immune cells to infiltrate the brain, aggravating the central inflammatory response. a key contributing factor to cognitive impairment, neuroinflammation may be the main mechanism behind illnesses linked to aging (23). further research could help evaluate whether early interventions and lifestyle modifications could lower dementia risk, for obesity and diabetes continue to be serious public health problems in the u.s today. how tbi’s can affect with alzheimer's disease as reported in the alzheimer's association traumatic brain injury and alzheimer's disease are both disastrous neurological disorders, whose complex is not yet understood. cerebrovascular pathology, a key element in both conditions, could represent a mechanistic link between ab/tau deposition after tbi and the development of alzheimer's disease. (24) more research is needed to fully understand the relationship between traumatic brain injury and alzheimer’s and to understand why moderate, severe and repeated mild traumatic brain injuries are at an increased risk. current research on how traumatic brain injuries changes brain chemistry indicates a relationship between traumatic brain injury hallmark protein abnormalities linked to alzheimer’s. within hours after injury, severe traumatic brain injury is seen to increase levels of beta amyloid, one hallmark protein (25). traumatic brain injuries affect over 1.7 million people every year and are often followed by changes in brain structure and function and by cognitive problems such as memory deficits, impaired social function, and difficulty with decision making. although mild tbi’s are known as concussion, it is also a risk for alzheimer's disease. using mri’s is a way to tell the similarities between alzheimer and tbi’s in how the brain's gray and white matter degrade after injury. in multiple brain areas of both tbi and alzheimer’s participants, the researchers found reduced cortical thickness when compared to the healthy controls. cortical thickness is roughly correlated with brain age and its thinning is often associated with reductions in attention, memory and verbal fluency, as well as with decreased ability to make decisions, integrate new information and adapt one’s behavior to new situations, among other deficits. (26) treatment as of 2022, the number of people living with alzheimer’s in texas is about 400,000. with no cure or true method of treatment, by the year of 2050, americans 65 and up with this disease are predicted to be as many as 12.7 million people (27). while there is no known cure at this time, there are several ways to manage the disease with more currently in the research phase. benedetti, et al. alzheimer´s disease https://doi.org/10.47488/dhrp.v2is2.60 dhr proceedings ǀ http://dhrproceedings.org 90 2022, vol. 2 no. s2 86-92 the current treatment that we have today is not a cure but options to manage the disease slow its progression. over the years, there has been a lot of progression in the understanding of pathophysiology, methods to diagnose the disease, and treatments. there are two categories of pharmacological therapy that are available to patients. they include the cholinesterase inhibitors, a group of medicines that block the normal breakdown of acetylcholine. donepezil, rivastigmine, and galantamine are the recommended therapies for people with mild, moderate, or severe alzheimer’s disease dementia (28). these methods are able to show beneficial effects on awareness, activities of daily living, behavior, and overall clinical rating (28). in the past ten years, the omega-3 fatty acid supplements including fish oil have gained a lot of attention owing to their cardiovascular benefits (28). “two recent randomized, controlled, double-blinded studies showed improvement in thinking and memory in patients with mci who took fish oil supplements, though these studies were limited by small sample size.” (28) there are also many other hands-on activities that patients can take part of to improve neuropsychiatric symptoms and their quality of life. several case studies show that art therapy has improved one's attention, provides pleasure, social behavior skills, and self-esteem (29). our future holds a lot of opportunities for new ways to help these patients who are developing alzheimer’s or have already been diagnosed with ad. the research into further treatments of alzheimer’s disease will include targeting of the neurofibrillary tangles and senile plaques. (28) all around there are debates on which anomaly mark to slow down neurologic decline and how soon the treatment should be initiated. spreading the information of clinical trials and including family members will bring in patients at the opportune time. by doing that, we will be able to slow these early stages of alzheimer’s. the clinical trials in ad committee in 2016 studied many of these trials to strive to identify the most effectful measures of patient recruitment and retention, infrastructure development, and patient evaluation including biomarkers and objective testing for the clinical end result. (2) when having to push through with trying to find the correct solution you will run into different encounters in learning which medicines will help, and which will not. with a collaborative attempt between researchers, exclusive and public funding, and screening of at-risk populations, a better predictor of successful clinical trials can be created. (28) conclusion alzheimer’s is one of the world’s most common diseases that we are facing today. the risk factors that come along with this disease are influencing our communities, families, and friends. our healthcare communities are coming together, researching, and learning new information every day that will eventually slow down the rise of cases. someday in the future alzheimer’s may be eradicated and no one will ever have to deal with the fear of this disease. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. alzheimer's disease facts and statistics. (2022). fisher center for alzheimer's research foundation. retrieved june 30, 2022, from https://www.alzinfo.org/understandalzheimers/alzheimers-disease-facts-andstatistics/ 2. soria lopez ja, gonzález hm, léger gc. alzheimer's disease. handb clin neurol. 2019;167:231-255. doi: 10.1016/b978-0-12804766-8.00013-3. pmid: 31753135. 3. breijyeh z, karaman r. comprehensive review on alzheimer's disease: causes and treatment. molecules. 2020 dec 8;25(24):5789. doi: 10.3390/molecules25245789. pmid: 33302541; pmcid: pmc7764106. 4. a. armstrong r. risk factors for alzheimer's disease. folia neuropathol. 2019;57(2):87-105. doi: 10.5114/fn.2019.85929. pmid: 31556570. mayo clinic. (2021, april 29). alzheimer's stages: how the disease progresses. mayo clinic.https://www.mayoclinic.org/diseaseshttps://www.alzinfo.org/understand-alzheimers/alzheimers-disease-facts-and-statistics/ https://www.alzinfo.org/understand-alzheimers/alzheimers-disease-facts-and-statistics/ https://www.alzinfo.org/understand-alzheimers/alzheimers-disease-facts-and-statistics/ https://www.mayoclinic.org/diseases-%0cconditions/alzheimers-disease/in-depth/alzheimers-stages/art-20048448#:~:text= benedetti, et al. alzheimer´s disease https://doi.org/10.47488/dhrp.v2is2.60 dhr proceedings ǀ http://dhrproceedings.org 91 2022, vol. 2 no. s2 86-92 conditions/alzheimers-disease/indepth/alzheimers-stages/art20048448#:~:text=there%20are%20five%2 0stages%20associated,dementia%20due%20 to%20alzheimer's%20disease. 6. alzheimer's association. (n.d.). alzheimer's stages early, middle, late dementia symptoms | alz.org. alzheimer's association. retrieved june 29, 2022, from https://www.alz.org/alzheimersdementia/stages 7. silva, m.v.f., loures, c.d.m.g., alves, l.c.v. et al. alzheimer’s disease: risk factors and potentially protective measures. j biomed sci 26, 33 (2019). https://doi.org/10.1186/s12929-019-0524-y 8. muñoz, s.s., garner, b. & ooi, l. understanding the role of apoe fragments in alzheimer’s disease. neurochem res 44, 1297–1305 (2019). https://doi.org/10.1007/s11064-018-2629 9. serrano-pozo, a. (2021, january 01). sciencedirect. 20(1), 68-80. https://doi.org/10.1016/s14744422(20)30412-9 10. munoz, s. (2018, september 17). https://doi.org/10.1007/s11064-018-2629-1 11. cacace, r. (2016). alzheimer's and dementia, 12(6), 733-738. https://doi.org/10.1016/j.jalz.2016.01.012 12. fortea, j., zaman, s. h., hartley, s., rafii, m. s., head, e., & carmona-iragui, m. (2021). alzheimer's disease associated with down syndrome: a genetic form of dementia. the lancet. neurology, 20(11), 930–942. https://doi.org/10.1016/s14744422(21)00245-3 13. budson, a. e. (2020, july 3). does air pollution cause alzheimer’s disease? https://www.health.harvard.edu/blog/doesair-pollution-cause-alzheimers-disease2020072320627 14. puckering, k. (2020, january 13). all you need to know about smoking and dementia. https://www.alzheimersresearchuk.org/blog/ all-you-need-to-know-about-smoking-anddementia/#:~:text=a%202019%20lancet% 20commission%20on,likely%20to%20deve lop%20alzheimer's%20disease. 15. gersema, e. (2017, june 12). poor diet, plus alzheimer’s gene, may fuel the disease. https://news.usc.edu/122919/poor-diet-plusalzheimers-gene-may-fuel-thedisease/#:~:text=a%20diet%20high%20in% 20cholesterol,a%20new%20usc%20study %20indicates. 16. pratt, e. (2021, june 28). how chronic stress may increase the likelihood of developing alzheimer’s disease. https://www.healthline.com/healthnews/how-chronic-stress-may-increase-thelikelihood-of-developing-alzheimersdisease#the-role-stress-may-play 17. haussmann, r., ganske, s., gruschwitz, a., werner, a., osterrath, a., lange, j., buthut, m., donix, k. l., linn, j., & donix, m. (2018). family history of alzheimer's disease and subjective memory performance. american journal of alzheimer's disease and other dementias, 33(7), 458– 462.https://pubmed.ncbi.nlm.nih.gov/29734 820/ 18. national institute aging. (2019, december 24). alzheimer's disease genetics fact sheet | national institute on aging. national institute on aging. retrieved june 30, 2022, from https://www.nia.nih.gov/health/alzheimersdisease-genetics-fact-sheet 19. kean, b., & sinha, s. (2020, june 3). athome sage test for alzheimer's and dementia detection. everyday health. retrieved june 30, 2022, from https://www.everydayhealth.com/alzheimers -disease/all-about-the-sage-test-foralzheimers-and-dementia-detection/ 20. baglietto-vargas, d., shi, j., yaeger, d. m., ager, r., & laferla, f. m. (2016). diabetes and alzheimer’s disease crosstalk. neuroscience and biobehavioral reviews, 64(complete), 272–287. https://doi.org/10.1016/j.neubiorev.2016.03. 005 21. picone, p., di carlo, m., & nuzzo, d. (2020). obesity and alzheimer's disease: molecular bases. the european journal of neuroscience, 52(8), 3944–3950. https://doi.org/10.1111/ejn.14758 22. pugazhenthi, s., qin, l., & reddy, p. h. (2017). common neurodegenerative pathways in obesity, diabetes, and alzheimer's disease. biochimica et biophysica acta. molecular basis of disease, 1863(5), 1037–1045. https://doi.org/10.1016/j.bbadis.2016.04.017 23. ramos-cejudo, j., wisniewski, t., marmar, c., zetterberg, h., blennow, k., de leon, m. j., & fossati, s. (2018). traumatic brain https://www.mayoclinic.org/diseases-%0cconditions/alzheimers-disease/in-depth/alzheimers-stages/art-20048448#:~:text= https://www.mayoclinic.org/diseases-%0cconditions/alzheimers-disease/in-depth/alzheimers-stages/art-20048448#:~:text= https://www.mayoclinic.org/diseases-%0cconditions/alzheimers-disease/in-depth/alzheimers-stages/art-20048448#:~:text= https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/alzheimers-stages/art-20048448#:~:text=there%20are%20five%20stages%20associated,dementia%20due%20to%20alzheimer's%20disease https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/alzheimers-stages/art-20048448#:~:text=there%20are%20five%20stages%20associated,dementia%20due%20to%20alzheimer's%20disease https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/alzheimers-stages/art-20048448#:~:text=there%20are%20five%20stages%20associated,dementia%20due%20to%20alzheimer's%20disease https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/alzheimers-stages/art-20048448#:~:text=there%20are%20five%20stages%20associated,dementia%20due%20to%20alzheimer's%20disease https://www.alz.org/alzheimers-dementia/stages https://www.alz.org/alzheimers-dementia/stages https://doi.org/10.1186/s12929-019-0524-y https://doi.org/10.1007/s11064-018-2629https://doi.org/10.1016/s1474-4422(20)30412-9 https://doi.org/10.1016/s1474-4422(20)30412-9 https://doi.org/10.1007/s11064-018-2629-1 https://doi.org/10.1016/s1474-4422(21)00245-3 https://doi.org/10.1016/s1474-4422(21)00245-3 https://www.health.harvard.edu/blog/does-air-pollution-cause-alzheimers-disease-2020072320627 https://www.health.harvard.edu/blog/does-air-pollution-cause-alzheimers-disease-2020072320627 https://www.health.harvard.edu/blog/does-air-pollution-cause-alzheimers-disease-2020072320627 https://www.alzheimersresearchuk.org/blog/all-you-need-to-know-about-smoking-and-dementia/#:~:text=a%202019%20lancet%20commission%20on,likely%20to%20develop%20alzheimer's%20disease. https://www.alzheimersresearchuk.org/blog/all-you-need-to-know-about-smoking-and-dementia/#:~:text=a%202019%20lancet%20commission%20on,likely%20to%20develop%20alzheimer's%20disease. https://www.alzheimersresearchuk.org/blog/all-you-need-to-know-about-smoking-and-dementia/#:~:text=a%202019%20lancet%20commission%20on,likely%20to%20develop%20alzheimer's%20disease. https://www.alzheimersresearchuk.org/blog/all-you-need-to-know-about-smoking-and-dementia/#:~:text=a%202019%20lancet%20commission%20on,likely%20to%20develop%20alzheimer's%20disease. https://www.alzheimersresearchuk.org/blog/all-you-need-to-know-about-smoking-and-dementia/#:~:text=a%202019%20lancet%20commission%20on,likely%20to%20develop%20alzheimer's%20disease. https://www.alzheimersresearchuk.org/blog/all-you-need-to-know-about-smoking-and-dementia/#:~:text=a%202019%20lancet%20commission%20on,likely%20to%20develop%20alzheimer's%20disease. https://www.alzheimersresearchuk.org/blog/all-you-need-to-know-about-smoking-and-dementia/#:~:text=a%202019%20lancet%20commission%20on,likely%20to%20develop%20alzheimer's%20disease. https://news.usc.edu/122919/poor-diet-plus-alzheimers-gene-may-fuel-the-disease/#:~:text=a%20diet%20high%20in%20cholesterol,a%20new%20usc%20study%20indicates. https://news.usc.edu/122919/poor-diet-plus-alzheimers-gene-may-fuel-the-disease/#:~:text=a%20diet%20high%20in%20cholesterol,a%20new%20usc%20study%20indicates. https://news.usc.edu/122919/poor-diet-plus-alzheimers-gene-may-fuel-the-disease/#:~:text=a%20diet%20high%20in%20cholesterol,a%20new%20usc%20study%20indicates. https://news.usc.edu/122919/poor-diet-plus-alzheimers-gene-may-fuel-the-disease/#:~:text=a%20diet%20high%20in%20cholesterol,a%20new%20usc%20study%20indicates. https://news.usc.edu/122919/poor-diet-plus-alzheimers-gene-may-fuel-the-disease/#:~:text=a%20diet%20high%20in%20cholesterol,a%20new%20usc%20study%20indicates. https://news.usc.edu/122919/poor-diet-plus-alzheimers-gene-may-fuel-the-disease/#:~:text=a%20diet%20high%20in%20cholesterol,a%20new%20usc%20study%20indicates. https://news.usc.edu/122919/poor-diet-plus-alzheimers-gene-may-fuel-the-disease/#:~:text=a%20diet%20high%20in%20cholesterol,a%20new%20usc%20study%20indicates. https://www.healthline.com/health-news/how-chronic-stress-may-increase-the-likelihood-of-developing-alzheimers-disease#the-role-stress-may-play https://www.healthline.com/health-news/how-chronic-stress-may-increase-the-likelihood-of-developing-alzheimers-disease#the-role-stress-may-play https://www.healthline.com/health-news/how-chronic-stress-may-increase-the-likelihood-of-developing-alzheimers-disease#the-role-stress-may-play https://www.healthline.com/health-news/how-chronic-stress-may-increase-the-likelihood-of-developing-alzheimers-disease#the-role-stress-may-play https://pubmed.ncbi.nlm.nih.gov/29734820/ https://pubmed.ncbi.nlm.nih.gov/29734820/ https://www.nia.nih.gov/health/alzheimers-disease-genetics-fact-sheet https://www.nia.nih.gov/health/alzheimers-disease-genetics-fact-sheet https://www.everydayhealth.com/alzheimers-disease/all-about-the-sage-test-for-alzheimers-and-dementia-detection/ https://www.everydayhealth.com/alzheimers-disease/all-about-the-sage-test-for-alzheimers-and-dementia-detection/ https://www.everydayhealth.com/alzheimers-disease/all-about-the-sage-test-for-alzheimers-and-dementia-detection/ https://doi.org/10.1111/ejn.14758 https://doi.org/10.1016/j.bbadis.2016.04.017 https://doi.org/10.1016/j.bbadis.2016.04.017 https://doi.org/10.1016/j.bbadis.2016.04.017 benedetti, et al. alzheimer´s disease https://doi.org/10.47488/dhrp.v2is2.60 dhr proceedings ǀ http://dhrproceedings.org 92 2022, vol. 2 no. s2 86-92 injury and alzheimer's disease: the cerebrovascular link. ebiomedicine, 28, 21– 30.https://doi.org/10.1016/j.ebiom.2018.01.0 21 24. alzheimer's association. (n.d.). traumatic brain injury. alzheimer's association. retrieved 06 30, 2022, from https://www.alz.org/alzheimersdementia/what-isdementia/related_conditions/traumaticbraininjury#:~:text=within%20hours%20after%2 0injury%2c%20severe,tau%20protein%2c %20another%20alzheimer%27s%20hallmar k 25. miller, j. (2021). brain changes following traumatic brain injury share similarities with alzheimer’s disease. jesse miller. https://news.usc.edu/185354/traumaticbrain-injury-tbi-alzheimers-disease-uscresearch 26. alzheimer's disease statistics. (2022, june 3). texas department of state health services. retrieved june 30, 2022, from https://www.dshs.texas.gov/alzheimers/statis tics.shtm 27. weller, j., & budson, a. (2018). current understanding of alzheimer's disease diagnosis and treatment. f1000research, 7, f1000 faculty rev-1161. https://doi.org/10.12688/f1000research.1450 6.1 28. chancellor, b., duncan, a., & chatterjee, a. (2014). art therapy for alzheimer's disease and other dementias. journal of alzheimer's disease: jad, 39(1), 1–11. https://doi.org/10.3233/jad-131295 https://doi.org/10.1016/j.ebiom.2018.01.021 https://doi.org/10.1016/j.ebiom.2018.01.021 https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/traumatic-brain-injury#:~:text=within%20hours%20after%20injury%2c%20severe,tau%20protein%2c%20another%20alzheimer%27s%20hallmark https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/traumatic-brain-injury#:~:text=within%20hours%20after%20injury%2c%20severe,tau%20protein%2c%20another%20alzheimer%27s%20hallmark https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/traumatic-brain-injury#:~:text=within%20hours%20after%20injury%2c%20severe,tau%20protein%2c%20another%20alzheimer%27s%20hallmark https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/traumatic-brain-injury#:~:text=within%20hours%20after%20injury%2c%20severe,tau%20protein%2c%20another%20alzheimer%27s%20hallmark https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/traumatic-brain-injury#:~:text=within%20hours%20after%20injury%2c%20severe,tau%20protein%2c%20another%20alzheimer%27s%20hallmark https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/traumatic-brain-injury#:~:text=within%20hours%20after%20injury%2c%20severe,tau%20protein%2c%20another%20alzheimer%27s%20hallmark https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/traumatic-brain-injury#:~:text=within%20hours%20after%20injury%2c%20severe,tau%20protein%2c%20another%20alzheimer%27s%20hallmark https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/traumatic-brain-injury#:~:text=within%20hours%20after%20injury%2c%20severe,tau%20protein%2c%20another%20alzheimer%27s%20hallmark https://news.usc.edu/185354/traumatic-brain-injury-tbi-alzheimers-disease-usc-research/ https://news.usc.edu/185354/traumatic-brain-injury-tbi-alzheimers-disease-usc-research/ https://news.usc.edu/185354/traumatic-brain-injury-tbi-alzheimers-disease-usc-research/ https://www.dshs.texas.gov/alzheimers/statistics.shtm https://www.dshs.texas.gov/alzheimers/statistics.shtm https://doi.org/10.12688/f1000research.14506.1 https://doi.org/10.12688/f1000research.14506.1 https://doi.org/10.3233/jad-131295 brittney benedetti1,2, shiv singh1,3, darlene vargas1,2, leith el-zaim1,4, ashely pruneda1,2, mia padron1,2, nadia ramirez1,5 genetics there are genetic risk factors that contribute to why alzheimer’s disease affects many individuals worldwide. according to researchers, approximately 70% of the risk of developing ad can be attributed to genetics (7). as one of the most severe neurod... the strongest genetic risk factor for sporadic alzheimer's disease is still the apoe 4 allele. however, there are currently no apoe-specific treatments available (9). the most important genetic risk factor for late-onset ad is the apoe 4 allele, but i... a second presenilin protein, known as presenilin 2, was found in the area connected to ad in a group of families known as volga-german descendants. it was discovered based on protein homology (psen2) (11). as per the alzheimer’s and dementia textbook ... the three eoad genes, which code for the presenilin 1 and 2 (psen1 and psen2) and the amyloid precursor protein (app), were shown to have high-penetrant mutations by genetic analysis of unusually large and informative monogenic pedigrees (11). special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.69 dhr proceedings ǀ http://dhrproceedings.org 93 2022, vol. 2 no. s2 93--99 commentary eating disorders in adolescence anevaeh escamilla 1,2, francis herrera 1,2, nevaeh areli serna 1,2, yeikol chapa 1,3, jasmin perez 1,3, monseratt ramos 1,3, angela anguiano 1,4, issac banda 1,4, arleen garcia 1,4 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2hebbronville high school, hebbronville, tx 3j.w. nixon high school, laredo, tx 4progreso early college high school, progreso, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg, texas, 78539 received 08/04/2022 accepted for publication 08/15/2022 published 08/15/2022 introduction adolescent eating disorders are on the rise, and this silent pandemic could be particularly alarming. eating disorders are severe, potentially fatal illnesses that affect people of all ages, particularly affecting adolescents' physical and psychological development (1). eating disorders affect people of all genders and racial and ethnic backgrounds and are recognized to have the highest mortality risk of all mental health illnesses. estimates indicate that approximately 30 million people in the united states suffer from an eating disorder. about 95 percent of the patients suffering from an eating disorder are between the ages of 12 to 25 (2). genetics, social, and psychological factors contribute to the risk of developing an eating disorder. some examples include the role of social media, inheritable conditions, and/or other mental illnesses. however, it's essential to realize that eating disorders involve more than just food and weight. eating disorders are characterized by secrecy and denial (3), so patients frequently conceal or falsely describe their symptoms out of shame or guilt. because mental health care is one of the most crucial components of rehabilitation, it is vital to understand eating disorders. if untreated, eating disorders can have serious adverse health effects such as organ failure or death. types of eating disorders eating disorders are different types of psychological illnesses that affect eating habits in adolescents that are severely harmful (4). there are various conditions in eating disorders, but only a few are most common in adolescents, such as anorexia nervosa, bulimia nervosa, binge eating disorder, rumination disorder, and lastly, avoidant/restrictive food intake disorder. anorexia nervosa carries one of the highest mortality rates in adolescent psychiatric illnesses (5). anorexia is a condition that causes restricted oral intake and consequent low body weight. with this illness, people tend to see themselves as overweight despite being severely underweight. this illness can also cause individuals to restrict their calorie intake and hyper-fixate their weight. bulimia nervosa is an illness that causes binge eating for a period of time that will apply gut escamilla, et al eating disorders https://doi.org/10.47488/dhrp.v2is2.69 dhr proceedings ǀ http://dhrproceedings.org 94 2022, vol. 2 no. s2 93-99 discomfort. individuals with bulimia disorder often force themselves to throw up after excessive food intake (6). binge eating disorder is commonly found in adolescents. this disorder causes an individual to eat excessively, but unlike bulimia, they do not purge (7). individuals with this eating disorder do not take note of their calorie intake and continue to eat food when they are uncomfortably full. purging can cause a feeling of lack of control and guilt. rumination disorder is one of the newest discovered food disorders that cause individuals to regurgitate food they have previously chewed and swallowed, re-chew it, and then re-swallow it or spit it out. this illness can cause regurgitation shortly after meal ingestion (8). rumination disorder occurs most commonly in adolescents. avoidant/restrictive food disorder is most commonly found in young adolescents that causes individuals to refuse to intake nutritional foods leading to low weight and dependence on supplemental feedings (9). individuals with this disorder are disturbed by foods due to a lack of interest in eating or a distaste for specific smells, tastes, colors, and more. prevalence in adolescents eating disorders can begin at any age; however, if left untreated, eating disorders may last for many years. eating disorders in the united states are prevalent because of environmental factors, which include events and influences in an individual's life, such as diet, culture, media, trauma, and social influences (10). approximately 2.7% of adolescents are affected by an eating disorder in the united states (11). females are more commonly diagnosed compared to males to have a diagnosis of anorexia nervosa or bulimia nervosa and being underweight. binge eating is more common in males than females, and they are more likely to get diagnosed. females are more likely to report weight dissatisfaction, dieting for weight control, and use of purging but are either as likely as males to report binge eating or excessive exercise for weight control (12). caucasians have a higher lifelong prevalence of eating disorders, particularly anorexia nervosa, bulimia nervosa, and binge eating disorder, compared to other ethnic groups (13). hispanics have elevated rates of any binge eating disorder but low prevalence of anorexia nervosa and bulimia nervosa (14). eating disorders are more common in lower socioeconomic status groups as they report having higher rates of disordered eating behavior, including vomiting, use of diet pills, diuretics, or laxatives as a means to lose weight (15). epidemiology and risk factors factors that contribute to eating disorders can be genetic, social, or psychological. eating disorders, especially non-specific ones, are common during childhood and adolescence. such diseases were attributed mainly to the family environment and exposure to the media (16). social and family environments are the most critical risk factors for eating disorders (16). family environments and meal times appeared to be fundamental in shaping eating behaviors and the development of diseases. the media and social environment have been related to the worship of thinness. additionally, eating disorders can be associated with nutritional problems, including malnourishment and disfigurement (16). genetic factors genetics can be a family history, and chemical imbalance narrates starvation and temperament traits. genetics are 40-50% of the risks of developing an eating disorder (17). for example, a child born to a mother with anorexia nervosa is 12% more likely to develop this eating disorder (17). health risks patients with anorexia have related cardiac issues that result in one-third of deaths (18). cardiac complications that occur among people with anorexia include bradycardia and hypotension. anorexia and bulimia are at greater risk for heart failure. the heartbeat of an individual with this disorder can be slower or faster than the regular heartbeat. up to 50% of people with a binge eating disorder (bed) have obesity (18). obesity increases the risks of heart disease, stroke, type 2 diabetes, and cancer. studies have found that people with bed have an even greater risk of developing health problems like sleep problems, chronic pain conditions, asthma, and irritable bowel syndrome (18). escamilla, et al eating disorders https://doi.org/10.47488/dhrp.v2is2.69 dhr proceedings ǀ http://dhrproceedings.org 95 2022, vol. 2 no. s2 93-99 effects on the body anorexia nervosa many women have many complications, but there is a history of eating disorders when trying to get pregnant later in the future. they will likely bleed during pregnancy, have a miscarriage, preterm birth, or induced abortion. it was proven with evidence that women with eating disorders or a history of eating disorders are more commonly known to have used hormonal birth control and to be moderate heavy smokers. these effects become severe for any woman trying to get pregnant after having problems with any associated eating disorder (19). another complication with anorexia nervosa is alterations of the gut microbiome. medical complications in the human body due to anorexia nervosa usually occur due to starvation and malnutrition, for example, sodium depletion, hypovolemia, hypophosphatemia, and hypomagnesemia (20). these disorders can also result in gastrointestinal complications, including gastric dilations and severe liver dysfunction. they are also at high risk of various arrhythmias. underweight patients are at risk of osteoporosis (21). anorexia also affects the body in four cardiovascular domains: structural, repolarization, conduction, hemodynamic, and peripheral vascular (22). bulimia nervosa bulimia nervosa causes the patient to overeat, and when binge eating, you can get diseases because your body can't handle the amount of food. these diseases include diabetes. diabetic patients are at high risk for hyperglycemia, ketoacidosis, and premature microvascular complications. patients with bulimia nervosa who vomit daily cause electrolyte aberrations from this. bulimia nervosa also increases the risk of cardiovascular diseases, including ischemic heart disease and death in females. effects that come to the patient from vomiting are trauma to the oral mucosa and pharynx and dental erosions. the parotid glands are also affected, and they develop sialadenosis. while the patient is vomiting increases intrathoracic and intra-alveolar pressures, leading to pneumomediastinum. excessive purging exposes the esophagus to gastric acid and damages the opening to the stomach. (23). binge eating the clinical importance of bed is related to its comorbidity with obesity and complications of being overweight. bed also comes with psychiatric symptoms like depression and anxiety, with concerns about one's image and weight. bed patients show relevant alexithymia and are deficient in emotional identification. eating impulsiveness has been related to more significant physical discomfort and worse quality of life. overeating can also lead to many health disorders such as diabetes, obesity, high blood pressure, high cholesterol, and heart problems (24). rumination disorder rumination can cause mental and physical distress to the patient causing problems with how they view life. this disorder also results in significant weight loss, especially in adolescents. more in-depth electrolyte disturbances and dental damages occur. these problems have been commonly found in patients diagnosed with rumination disorder. another common thing that develops with this disorder is anxiety, depression, and somatization (25). avoidant/restrictive food disorder most patients with this eating disorder have neurological or gastroenterological disorders. they diagnose this when a child fails to meet their nutritional needs leading to significant weight loss. the comorbidities of restrictive food disorder are autism spectrum disorder, cognitive impairment, and intellectual disability (26). mental health body dysmorphia people with bdd have some compulsive behaviors, such as combing their hair in a specific way. these behaviors are typically hard to control or resist. patients with bdd are also associated with feelings and guilt and shame, causing them to have high rates of suicidal ideation and suicidal attempts (27). many patients don't acknowledge that there's help for them, such as effective treatment and therapy. they will hide and/or misrepresent their symptoms out of guilt or embarrassment. unfortunately, patients often have difficulty with intimate relationships and social functions, but it's not only that they also have academic or occupational problems. bdd is associated with biological, psychological, and environmental factors. usually, bdd develops with past traumas such as abuse and violence; patients are more likely to have flashbacks that make them recall their pain very clearly. bdd patients took a survey, escamilla, et al eating disorders https://doi.org/10.47488/dhrp.v2is2.69 dhr proceedings ǀ http://dhrproceedings.org 96 2022, vol. 2 no. s2 93-99 and 68% suffer from emotional neglect, 56% suffer from emotional abuse, 33.3% suffer from physical neglect, 34.7% suffer from physical abuse, and 28% from sexual abuse. these results show the understanding that bdd patients have been associated with a low-quality life and an increase in suicidality (27). social media effect on eating disorders eds have one of the highest medical complication rates among disorders and put adolescents at increased risk for many physical problems. eds often happen when you're an adolescent; intervening is crucial to the outcome, especially during youth development. by age 6, girls are exposing concerns about their shape and weight. however, teens are unlikely to seek treatment and ask for help with their eds for countless reasons but mainly fearing what their parents might say when they disclose their symptoms or not being ready for personal treatment. only about 20% of adolescents seek professional help putting those who haven't at more risk of progressing illnesses and poorer outcomes (28). research shows teens engaging with social media idealize thinness and are more likely to suffer from eating disorders or body image concerns; social media plays a crucial role in these concerns. 97% of adolescent’s report using at least one social media such as youtube, instagram, snapchat, facebook, twitter, tumblr, or reddit. in addition, 95% of adolescents own or have access to a smartphone daily (28). one study found that about 52% of girls and 45% of boys often skip meals, do heavy exercises, and other behaviors associated with eating disorders. of all participants, 75% of girls and 70% of boys were found to have at least one social media account, with instagram being the most common. (29) suicidality suicidal attempts and death caused by suicide are common in eds. an estimate of suicide attempts ranges broadly from 3.0% to 40%. data from an epidemiologic survey shows that higher prevalence of lifetime suicide attempts, especially in people with anorexia nervosa binge eating, followed by 31.4% for bulimia, 22.9% for binge eating disorder, and 15.7% for an restricting type (30). the national us epidemiologic survey states between 17% 45% reported a suicide attempt before the onset of their eds. some possible co-occurrences are disorders such as depression, bipolar disorder, substance abuse, psychological and personality traits, self-image, early cognitive schema, interceptive deficits, alexithymia, and impulsivity (30). obsessive compulsive disorder research shows that 14-30% of patients with eating disorders tie in with obsessive-compulsive traits and obsessive-compulsive personality disorder. ocd is frequently comorbid with eds, with 20-60% of patients with eds having a lifetime history of having ocd; ocd can also predict future development with anorexia. ocd rates are higher for females with 718% and 0%-5% for male patients; the patients included in those percentages have or had an ed (31). treatment eating disorder treatment depends on your disorder and symptoms. it combines psychological therapy, medical monitoring, nutrition education, selfhelp, partial hospital, intensive outpatient, and medication therapy (32). medications the most common medications used to treat eating disorders are antidepressants. antidepressants may be beneficial if you have bulimia or a binge eating disorder. it can also help reduce symptoms of anxiety or depression, which are seen in those with eating disorders. you could need to take medication for physical health problems caused by the eating disorder (32). behavioral therapy eating disorder treatments also involve addressing other health problems caused by an eating disorder which can be consequential or even lifethreatening if they go untreated for too long. suppose an eating disorder doesn't improve with quality treatment or causes health problems. in that case, you may need hospitalization, an inpatient program, and organized eating disorder treatment to maintain your physical and mental health and return to a healthy weight (33). whether you start by seeing your primary care practitioner or some type of mental health escamilla, et al eating disorders https://doi.org/10.47488/dhrp.v2is2.69 dhr proceedings ǀ http://dhrproceedings.org 97 2022, vol. 2 no. s2 93-99 professional, you'll likely benefit from a referral to a team of professionals who concentrate on eating disorder treatment. members of your treatment team may include a mental health professional, a registered dietitian, a medical or dental specialist, your partner, your parents, or other family members (34). managing an eating disorder can be a longterm challenge. you would perhaps need to regularly see members of your treatment team, even if you’re eating disorder and related health problems are under control (34). prognosis an eating disorder, anorexia nervosa, can be a deadly disease during adolescence and is and has the highest fatality rate of all psychiatric conditions (5). treatment for adolescents can be complex and has limited treatment options. doctors' training in caring for people with eating disorders and their practical experience with underweight adolescents varies. the earlier the treatment, the higher the chances of recovery (1). by the end of treatment, most patients are within the normal weight range. an overview of the presentation and treatment of anorexia nervosa in adolescents is provided in this study, with a focus on the evaluation and management of physical health hazards, such as refeeding syndrome. some researchers have found that approximately 70% of adolescents recover better than adults (35). however, recovery is a life-long process, and therapy should remain an ongoing recovery due to the fact that some habits may resurface again, like perfectionism. it has been estimated that 50% of patients have a full recovery, 30% improve, and 20% remain chronically ill (5). conclusion it is crucial that people do not underestimate eating disorders and their impacts as a result. eating disorders, ed, are extremely serious, even fatal, diseases. each person who is impacted by an ed experiences it differently, and each person's recovery is unique. furthermore, it is not uncommon for people to go through extensive periods of therapy due to setbacks or a relapse. adolescents are more likely to recover than adults that have been dealing with an ed for years. although it is never too late to get help, getting help as soon as you are diagnosed is best for your physical and mental health. there is so much that can be done for these individuals who suffer. one such action we can take to prevent eating disorders is to educate parents and those who are around adolescents. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected and region one esc paths references 1. hornberger, l. l., lane, m. a., & committee on adolescence (2021). identification and management of eating disorders in children and adolescents. pediatrics, 147(1), e2020040279. https://doi.org/10.1542/peds.2020-040279 2. reynolds, kathryn m.d., reese, jasmine m., md. m.p.h. and lucrezia, samantha, m.d. (n.d.). eating disorder facts. johns hopkins all children's hospital. https://www.hopkinsallchildrens.org/service s/pediatric-and-adolescentmedicine/adolescent-and-young-adultspecialty-clinic/eating-disorders/eatingdisorder-facts 3. reese, j. (2022). assessment and treatment of eating disorders in adolescents. contemporary ob/gyn, 67(5), 26–29. 4. frank, g., shott, m. e., & deguzman, m. c. (2019). the neurobiology of eating disorders. child and adolescent psychiatric clinics of north america, 28(4), 629–640. https://doi.org/10.1016/j.chc.2019.05.007 5. neale, j., & hudson, l. d. (2020). anorexia nervosa in adolescents. british journal of hospital medicine (london, england: 2005), 81(6), 1–8. https://doi.org/10.12968/hmed.2020.0099 6. kaye w. (2008). neurobiology of anorexia and bulimia nervosa. physiology & behavior, 94(1), 121–135. https://doi.org/10.1016/j.physbeh.2007.11.0 37 7. bohon c. (2019). binge eating disorder in children and adolescents. child and adolescent psychiatric clinics of north escamilla, et al eating disorders https://doi.org/10.47488/dhrp.v2is2.69 dhr proceedings ǀ http://dhrproceedings.org 98 2022, vol. 2 no. s2 93-99 america, 28(4), 549–555. https://doi.org/10.1016/j.chc.2019.05.003 8. martinez, m., rathod, s., friesen, h. j., rosen, j. m., friesen, c. a., & schurman, j. v. (2021). rumination syndrome in children and adolescents: a mini review. frontiers in pediatrics, 9, 709326. https://doi.org/10.3389/fped.2021.709326 9. thomas, j. j., lawson, e. a., micali, n., misra, m., deckersbach, t., & eddy, k. t. (2017). avoidant/restrictive food intake disorder: a three-dimensional model of neurobiology with implications for etiology and treatment. current psychiatry reports, 19(8), 54. https://doi.org/10.1007/s11920017-0795-5 10. the different causes of eating disorders https://www.verywellmind.com/whatcauses-eating-disorders-4121047 11. national institute of mental health. retrieved from https://www.nimh.nih.gov/health/statistics/e ating-disorders#part_2571 12. striegel-moore rh, rosselli f, perrin n, debar l, wilson gt, may a, kraemer hc. gender difference in the prevalence of eating disorder symptoms. int j eat disord. 2009 jul;42(5):471-4. doi: 10.1002/eat.20625. pmid: 19107833; pmcid: pmc2696560. 13. cheng zh, perko vl, fuller-marashi l, gau jm, stice e. ethnic differences in eating disorder prevalence, risk factors, and predictive effects of risk factors among young women. eat behav. 2019 jan; 32:2330. doi: 10.1016/j.eatbeh.2018.11.004. epub 2018 nov 23. pmid: 30529736; pmcid: pmc6382562. 14. alegria m, woo m, cao z, torres m, meng xl, striegel-moore r. prevalence and correlates of eating disorders in latinos in the united states. int j eat disord. 2007 nov;40 suppl(suppl): s15-21. doi: 10.1002/eat.20406. pmid: 17584870; pmcid: pmc2680162. 15. gibbons, p. (2001). the relationship between eating disorders and socioeconomic status: it's not what you think. nutrition noteworthy, 4(1). retrieved from https://escholarship.org/uc/item/1k70k3fd 16. gonçalves jde a, moreira ea, trindade eb, fiates gm. eating disorders in childhood and adolescence. rev paul pediatr. 2013 janmar;31(1):96-103. english, portuguese. doi: 10.1590/s0103-05822013000100016. pmid: 23703051.s 17. lonergan, a.r. (2020). protect me from my selfie: examining the association between photo-based social media behaviors and selfreported eating disorders in adolescence. international journal of eating disorders. https://onlinelibrary.wiley.com/doi/full/10.1 002/eat.23256 18. mitchell je. medical comorbidity and medical complications associated with bingeeating disorder. int j eat disord. 2016 mar;49(3):319-23. doi: 10.1002/eat.22452. epub 2015 aug 27. pmid: 26311499. 19. o'brien km, whelan dr, sandler dp, hall je, weinberg cr. predictors and long-term health outcomes of eating disorders. plos one. 2017 jul 10;12(7):e0181104. doi: 20. voderholzer u, haas v, correll cu, körner t. medical management of eating disorders: an update. curr opin psychiatry. 2020 nov;33(6):542-553. doi: 10.1097/yco.0000000000000653. pmid: 32925184.10.1371/journal.pone.0181104. pmid: 28700663; pmcid: pmc5507321. 21. mitchell je, crow s. medical complications of anorexia nervosa and bulimia nervosa. curr opin psychiatry. 2006 jul;19(4):43843. doi: 10.1097/01.yco.0000228768.79097.3e. pmid: 16721178. 22. sachs kv, harnke b, mehler ps, krantz mj. cardiovascular complications of anorexia nervosa: a systematic review. int j eat disord. 2016 mar;49(3):238-48. doi: 10.1002/eat.22481. epub 2015 dec 29. pmid: 26710932. 23. nitsch a, dlugosz h, gibson d, mehler ps. medical complications of bulimia nervosa. cleve clin j med. 2021 jun 2;88(6):333-343. doi: 10.3949/ccjm.88a.20168. pmid: 34078617. 24. amianto f, ottone l, abbate daga g, fassino s. binge-eating disorder diagnosis and treatment: a recap in front of dsm-5. bmc psychiatry. 2015 apr 3;15:70. doi: 10.1186/s12888-015-0445-6. pmid: 25885566; pmcid: pmc4397811. 25. kusnik a, vaqar s. rumination disorder. 2022 may 5. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2022 jan–. pmid: 35015429. 26. mairs r, nicholls d. assessment and treatment of eating disorders in children and adolescents. arch dis child. 2016 dec;101(12):1168-1175. doi: 10.1136/archdischild-2015-309481. epub 2016 jun 28. pmid: 27381185. https://onlinelibrary.wiley.com/doi/full/10.1002/eat.23256 https://onlinelibrary.wiley.com/doi/full/10.1002/eat.23256 https://onlinelibrary.wiley.com/doi/full/10.1002/eat.23256 escamilla, et al eating disorders https://doi.org/10.47488/dhrp.v2is2.69 dhr proceedings ǀ http://dhrproceedings.org 99 2022, vol. 2 no. s2 93-99 27. hong k, nez govorova v, uzunova g, schlussel d, hollander e. pharmacological treatment of body dysmorphic disorder. curr neuropharmacol. 2019;17(8):697-702. doi: 10.2174/1570159x16666180426153940. pmid: 29701157; pmcid: pmc7059151. 28. kasson e, vázquez mm, doroshenko c, fitzsimmons-craft ee, wilfley de, taylor cb, cavazos-rehg pa. exploring social media recruitment strategies and preliminary acceptability of an mhealth tool for teens with eating disorders. int j environ res public health. 2021 jul 28;18(15):7979. doi: 10.3390/ijerph18157979. pmid: 34360270; pmcid: pmc8345665. 29. sm (2019). the relationship between social media use and disordered eating in young adolescents. international journal of eating disorders. https://onlinelibrary.wiley.com/doi/abs/10.1 002/eat.23198 30. rania m, monell e, sjölander a, bulik cm. emotion dysregulation and suicidality in eating disorders. int j eat disord. 2021 mar;54(3):313-325. doi: 10.1002/eat.23410. epub 2020 nov 18. pmid: 33205495; pmcid: pmc7984062. 31. bang l, kristensen ub, wisting l, stedal k, garte m, minde å, rø ø. presence of eating disorder symptoms in patients with obsessive-compulsive disorder. bmc psychiatry. 2020 jan 30;20(1):36. doi: 10.1186/s12888-020-2457-0. pmid: 32000754; pmcid: pmc6993325. 32. eating disorder treatment: know your options. mayo clinic. https://www.mayoclinic.org/diseasesconditions/eating-disorders/in-depth/eatingdisorder-treatment/art-20046234. date accessed: 02aug2022 33. hospitalization for eating disorders. verywellmind. https://www.verywellmind.com/inpatienthospitalization-1138353. date accessed: 02aug2022 34. treating eating disorders in primary care. american family physician. https://www.aafp.org/pubs/afp/issues/2008/0 115/p187.html. date accessed: 02aug2022 35. ackard, d. m., richter, s., egan, a., & cronemeyer, c. (2014). poor outcome and death among youth, young adults, and midlife adults with eating disorders: an investigation of risk factors by age at assessment. the international journal of eating disorders, 47(7), 825–835. https://doi.org/10.1002/eat.22346 2021, vol. 1 (2) 5 https://doi.org/10.47488/dhrp.v1i2.9 http://dhrproceedings.org 5 © dhr health institute for research and development trauma bulletin what does a level 1 trauma center mean for the valley? megan molina1 1 trauma prevention and outreach, dhr trauma services, dhr health, edinburg, tx, usa e-mail: meg.molina@dhr-rgv.com received 03/02/2021 accepted for publication 03/03/2021 published 03/05/2021 keywords: nursing; trauma; injury; emergency; community as a new nurse, i didn’t understand what the different levels of trauma meant. i just knew that patient’s came into the emergency room (er), and we did everything we could to take care of them: this was six years ago. as i grew as a nurse, so did my understanding of the trauma system. there were times that a patient had an injury that required a special service to see them, for example, an eye injury, and the specialist wasn’t available to see them, so the patient had to be transferred to another hospital, frequently outside the valley. after three years of working at a level 3 trauma center i was accepted into a trauma nurse fellowship in san antonio (sa) at a level 1 trauma center. it wasn’t until i started working there that i fully understood what it meant to function as a level 1 trauma center. i learned that every patient who came through our doors would receive all the care they needed in one place. there would be no need to transfer to another facility or city. while working at this level 1 facility, i also learned that we received a large amount of transfer patients from surrounding towns and cities. one transfer i remember clearly was an older man who had sustained an eye injury while working in his yard. he was flown in by helicopter from edinburg, texas. the patient expressed that he was worried about the flight’s cost, his wife driving the 4hour drive alone at night, and where she would stay while he was in the hospital in sa. although retired, he worked a few days a week at a local business, and he also voiced concern about missing days at work. had this patients’ needs been met by his local hospital in the rio grande valley, he would have forgone the extra expense of transfer and lodging for his wife. furthermore, the emotional stress he suffered due to the worry he had for his wife’s travel and missed work could have been avoided. to me, a level 1 trauma center in the rio grande valley means that our community can receive all the care they need in one place, without having the extra financial and emotional burden that a transfer causes. aside from this, a level 1 trauma center also brings many resources to community. hands on training for emergency medical technicians (emt’s), community education, injury prevention, and a higher level of care for our patients are opportunities that a level 1 trauma center brings. although it was a sacrifice leaving the rio grande valley, my home, my family, and my friends the experience i gained and have now been able to bring back and apply for the benefit of my community makes it all worth it. diclosures mm clinical qualifications: bsn, rn, tcrn. she declares no conflicts of interest. references no references used in this document. 2021, vol. 1 (s4) 13-14 https://doi.org/10.47488/dhrp.v1is4.26 http://dhrproceedings.org 13 © dhr health institute for research and development editorial messenger rna vaccines are safe & effective and do not modify host dna despite the fact that over 5.3 billion doses of covid-19 vaccines have been administered globally, there still exists measurable hesitancy in a select cohort of the population to get vaccinated. this reluctance seems to be more evident towards messenger rna (mrna) vaccines which is attributed largely to misinformation about their safety and efficacy and the unfounded fear that they may integrate into host dna thus modifying it permanently. in this editorial, we plan to provide scientific evidence to repudiate these misconceptions and to alleviate concerns related to covid-19 mrna vaccines. on december 11, 2020, us food & drug administration (fda) issued its first emergency use authorization (eua) for pfizer/biontech covid-19 vaccine for the prevention of covid19 caused by sars-cov-2 in individuals 16 years of age and over (1). the pfizer/biontech vaccine is a nucleoside-modified mrna encoding for the viral spike glycoprotein of sars-cov-2 formulated in lipid particle (1). on may 10, 2021, fda issued another eua approving the use of pfizer/biontech vaccine for prevention of covid-19 in individuals 12-15 years of age (2). given the high risk of infection with the delta variant of vaccinated individuals with immunosuppressed status, on august 12, 2021, fda modified its eua allowing pfizer/biontech vaccine to be administered as a third dose to this select cohort of patients. with the availability of additional safety and efficacy data from millions of people who have been vaccinated supplemented by that obtained from double-blinded placebo-controlled clinical trials, pfizer submitted a biologics license application (bla) with fda requesting full approval of the pfizer/biontech vaccine for use in individuals 12 years of age and older. after careful review, fda approved pfizer’s bla on august 23, 2021, making it the first and only vaccine for prevention of infection with sars-cov-2 (3). pfizer/biontech vaccine is now marketed under the generic name of comirnaty. subsequently, on december 18, 2020, fda issued another eua for moderna covid-19 vaccine for the prevention of covid-19 caused by sarscov-2 in individuals 18 years of age and over (4). the formulation of moderna’s mrna vaccine is very similar to pfizer/biontech vaccine and was recommended at a dosing regimen of two doses administered one month apart. moderna mrna vaccine was also approved by the fda for a third dose in select vaccinated immunocompromised individuals who are at high risk of developing infection with sars-cov-2. the process outlined above underscores the scrupulous details with which, the federal regulatory agencies review and approve eua’s and bla’s. this process is stringently coordinated by various independent oversight committees including but not limited to the advisory committee on immunization practices – an entity within the us centers for disease control & prevention that is composed of experts in the field of infectious diseases and immunology and is responsible for providing guidance for the most effective control of diseases that can be prevented using vaccines. both pfizer/biontech and moderna vaccines are strands of messenger ribonucleic acid (mrna) encapsulated in lipid nanoparticles. the mrna encodes for the antigenic glycoproteins of the spike (s) domain of sars-cov-2 with two proline substitutions (k986p and v987p mutations) which, stabilizes the perfusion conformation of the glycoprotein. once delivered by intramuscular administration, the lipid nanoparticles facilitate the uptake of the mrna vaccine by the host antigen presenting cells (such as dendritic cells or macrophages) and its entry into the cytosol (the part of the cell that is outside the nucleus which houses the dna) [figure 1]]. utilizing the host cell’s dhrp, 2021, vol. 1 (s4) 13-14 editorial http://dhrproceedings.org 14 © dhr health institute for research and development ribosomes (organelle that help in protein synthesis), the mrna vaccine is translated into spike proteins which are presented on the cell surface to raise t and b cell responses. the mrna vaccine in the cytosol is degraded by the cell in a few days whereas, similar to other proteins made by the body, the spike protein survives for a few weeks and is ultimately cleared from the system. figure 1: the normal “physiological” pathway utilized by the covid-19 mrna vaccines to produce spike proteins that raise both cell and antibody mediated immune responses. in conclusion, mrna-based vaccines are safe, effective, and capable of raising both antibodymediated and cellular immune responses against sars-cov-2. additionally, all available scientific data provides unequivocal evidence that mrnabased vaccines follow the normal physiological pathways and once they enter, they remain confined to the extra-nuclear part of the host cell and are not designed to gain entry into the nucleus and are therefore incapable of modifying the dna. gaining public confidence is paramount in the success of the ongoing vaccination efforts to mitigate the spread of covid-19. therefore, every effort must be made to discount the misinformation and provide to the community facts that are informed by strong scientific evidence. references 1. us food and drug administration’s letter of emergency use authorization for pfizer/biontech mrna vaccine for individuals 17 years of age and older. december 11, 2020, https://nps.edu/documents/111291366/124403968/pfizerbiontech+covid19+vaccine+eua+loa+%2811+dec+2020%29.pdf/106e966 2-956c-aa94-8d4b-a945a6a10b87?t=1608071313236 2. us food and drug administration’s letter of emergency use authorization for pfizer/biontech mrna vaccine for individuals 12-16 years of age. may 10, 2021. https://www.fda.gov/media/144412/download 3. us food and drug administration’s letter of approval of biologics license application for pfizer/biontech vaccine. august 23, 2021. https://www.fda.gov/media/151710/download 4. us food and drug administration’s letter of emergency use authorization for moderna mrna vaccine. december 18, 2020. https://immunize.utah.gov/wpcontent/uploads/2020/12/moderna_covid19_vaccine_eua_letter_of_authorization.pdf sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 manish singh, md, facs chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas disclosures: none orcid: manish singh: https://orcid.org/0000-00034146-3282 https://nps.edu/documents/111291366/124403968/pfizer-biontech+covid-19+vaccine+eua+loa+%2811+dec+2020%29.pdf/106e9662-956c-aa94-8d4b-a945a6a10b87?t=1608071313236 https://nps.edu/documents/111291366/124403968/pfizer-biontech+covid-19+vaccine+eua+loa+%2811+dec+2020%29.pdf/106e9662-956c-aa94-8d4b-a945a6a10b87?t=1608071313236 https://nps.edu/documents/111291366/124403968/pfizer-biontech+covid-19+vaccine+eua+loa+%2811+dec+2020%29.pdf/106e9662-956c-aa94-8d4b-a945a6a10b87?t=1608071313236 https://nps.edu/documents/111291366/124403968/pfizer-biontech+covid-19+vaccine+eua+loa+%2811+dec+2020%29.pdf/106e9662-956c-aa94-8d4b-a945a6a10b87?t=1608071313236 https://www.fda.gov/media/144412/download https://www.fda.gov/media/151710/download https://immunize.utah.gov/wp-content/uploads/2020/12/moderna_covid-19_vaccine_eua_letter_of_authorization.pdf https://immunize.utah.gov/wp-content/uploads/2020/12/moderna_covid-19_vaccine_eua_letter_of_authorization.pdf https://immunize.utah.gov/wp-content/uploads/2020/12/moderna_covid-19_vaccine_eua_letter_of_authorization.pdf https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0003-4146-3282 https://orcid.org/0000-0003-4146-3282 2021, vol. 1 (s4) 11-12 https://doi.org/ 10.47488/dhrp.v1is4.25 http://dhrproceedings.org 11 © dhr health institute for research and development editorial covid-19 vaccination during pregnancy and breast feeding is safe and effective for the mother, the unborn child and the baby since the start of this pandemic, over 38.9 million people have been diagnosed with sars-cov-2 infection in the united states and over 638,000 people have died (1). with the rampant spread of the delta variant, in the last 28 days alone, over 3.7 million people have been diagnosed with covid19 in the united states alone and in the last 14 days, more than 150,000 patients/day have been diagnosed with sars-cov-2 infection (1). these observations are particularly disconcerting given the fact that we have three effective vaccines that have been approved by the us food and drug administration for use in the united states which has resulted in the vaccination of over 369 million people of which, more than 173 million have been fully vaccinated (2, 3). women who are pregnant, those trying to become pregnant, and/or breast feeding are particularly vulnerable to infection with the delta variant of sars-cov-2. despite the overwhelming evidence of the safety and efficacy of available vaccines in this vulnerable population, less than 25% of pregnant and breastfeeding women are vaccinated. these perturbing statistics have resulted in a rapid rise in hospitalizations of this vulnerable population with serious consequences for both the mother and the unborn child. once diagnosed, many of the patients in this susceptible population are being treated with the cocktail of regen-cov monoclonal antibody infusion which has been hailed as a “miracle” therapeutic intervention. however, it must be underscored that infusion of monoclonal antibodies provides only transient protection and it must not be considered as an alternative to vaccination. there are many compounding factors that have guided this high level of hesitation among pregnant and breast-feeding women from getting vaccinated. misinformation and its amplification in the social media are perhaps the single most important factor leading to this observed outcome. it is therefore imperative that scientifically proven facts are considered while making such crucial decisions. evidence concerning the safety and effectiveness of approved covid-19 vaccines has been growing suggesting that the benefits far outweigh any known or potential risk in this population. furthermore, contrary to the prevailing misinformation about the covid-19 vaccines, there is no evidence that they cause any issues related to fertility in both men and women and is safe for the unborn baby as well as those being breastfed. based on the available data that is supported by observations in our high-volume women’s hospital – a level iv maternal facility, we conclude that pregnant women are more susceptible to sarscov-2 infection and getting a covid-19 vaccine can protect them from severe illness. additionally, after reviewing all the available scientific data, we have also determined that the available covid-19 vaccines are safe and effective and that the benefits of vaccination far outweigh the risk. we therefore recommend that all pregnant women, those trying to get pregnant and/or breast feeding should seriously consider getting vaccinated. references 1. covid-19 dashboard – coronavirus resource center, johns hopkins university of medicine. https://coronavirus.jhu.edu/map.html (accessed august 30, 2021; 15:21 hrs; cst) 2. vasireddy d, atluri p, malayala sv, vanaparthy r, mohan g. review of covid-19 vaccines approved in the united states of america for emergency use [published correction appears in j clin med res. 2021 jul;13(7):412]. j clin med res. 2021;13(4):204-213. doi:10.14740/jocmr4490 3. covid data tracker – centers for disease control and prevention. https://covid.cdc.gov/covid-datatracker/#vaccinations_vacc-total-admin-rate-total (accessed august 30, 2021; 19:27 hrs; cst) https://coronavirus.jhu.edu/map.html https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total dhrp, 2021, vol. 1 (s4) 11-12 editorial http://dhrproceedings.org 12 © dhr health institute for research and development sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 efrain vela, md chief medical officer, women’s hospital, dhr health, 2821 michael angelo drive, edinburg, tx 78539 disclosures: none manish singh, md, facs chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas disclosures: none orcid: manish singh: https://orcid.org/0000-00034146-3282 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0003-4146-3282 https://orcid.org/0000-0003-4146-3282 2021, vol. 1 (s4) 4-5 https://doi.org/dhrp.v1is4.14 http://dhrproceedings.org 4 © dhr health institute for research and development commentary engineering of viruses and pathogens for gain-of-function research sohail rao, md, ma, dphil1, 2 and manish singh, md, facs3 1 executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas 78539 and president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0001-5027-9992 2 correspondence should be addressed to: sohail rao, md, ma, dphil., dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. tel: (956) 362-2387. e-mail: s.rao@dhr-rgv.com 3 chief executive officer, dhr health, 5501 s. mccoll road, edinburg tx 78539 orcid: manish singh: https://orcid.org/0000-0003-4146-3282 received 05/18/2021 accepted for publication 06/08/2021 published 06/08/2021 keywords: ethics, laboratory, pathogens, influenza, niaid, gain of function ethical concerns related to engineering of viruses and pathogens for gain-of-function (gof) research has been widely debated in the literature (1). scientists are conflicted as to the value of gof research which has been used in the past to enhance viral pathogenicity, transmissibility, antigenicity, and tropism (2-4). the primary objective of these experiments was to gain a better understanding of the pathogen, allowing investigators to develop a more reliable predictive models for emerging infectious diseases and to combat them with effective vaccines and other therapeutic agents. this issue was recently highlighted during a u.s. congressional hearing aimed at elucidating the origin of the sars-cov-2 pandemic that has infected over 173 million worldwide and has resulted in the death of over 3.7 million people (5, 6). in us alone, sars-cov-2 has infected over 33 million and caused the death of over 594,000 people (7). perhaps the most controversial research related to gof was the modification of h5ni avian flu virus (8). in these experiments, the investigators used reverse genetics that enhanced the lethality of the virus, confirming that h5n1 can jump from birds to mammals and could be efficiently transmitted between humans. these studies that were funded by the national institute of allergy and infectious disease (niaid) raised numerous ethical and public health concerns (9). it was argued that the risk posed by the inadvertent escape of laboratory engineered h5n1 into the community far outweighs the benefit that would be gained from these highly perilous experiments. the controversy escalated when the national science advisory board for biosecurity (nsabb) issued its recommendation that the controversial h5n1 reports be published with significant redactions (10). nsabb recommended that methodology and other details that could enable replication of the experiments by those who seek to do harm are to be redacted. this controversial research and the nsabb recommendation divided the scientific community, which recognized that the easily transmitted laboratory engineered gof h5n1 could be extraordinarily lethal. in 2014, a series of mishaps in which highly pathogenic microbes were mishandled by various laboratories in the u.s. centers for disease control and prevention (cdc) resulted in closure of two labs and halted some biological shipments (11). the cases included an accidental shipment of live anthrax; the discovery of forgotten, live smallpox samples; and a newly revealed incident in which a dangerous influenza strain was accidentally shipped from cdc to another laboratory. these and other similar mishaps involving gof experiments resulted, in the issuance of a moratorium by the u.s. government pausing deliberative process and research funding for selected gof research involving influenza, mers, and sars viruses in 2014 (12). subsequent to implementation of this “pause,” both the national research council and the institute of medicine organized a number of symposiums to discuss the potential risks and benefits of gof research. these deliberations ultimately resulted in the publication by nsabb https://orcid.org/0000-0001-5027-9992 mailto:s.rao@dhr-rgv.com https://orcid.org/0000-0003-4146-3282 dhrp, 2021, vol. 1 (s4) 4-5 viral gain-of-function http://dhrproceedings.org 5 © dhr health institute for research and development "recommendations for the evaluation and oversight of proposed gain-of-function research" (13). this was followed by the publication by the us department of health & human services "recommended policy guidance for departmental development of review mechanisms for potential pandemic pathogen care and oversight" (p3co) (14). with these p3co recommendations in place, in 2017, the nih lifted the moratorium into gof research because it was deemed to be important in helping identify, understand, and develop strategies and effective countermeasures against rapidly evolving pathogens that pose a threat to public health (15). with the lifting of this moratorium, niaid through an intermediate organization, funded gof research to be conducted on bat coronavirus in collaboration with the institute of virology, wuhan, china (16). the primary objective of this funding was to conduct gof research for the purpose of understanding how bat coronaviruses could mutate to attack humans. it is unclear what and/or how this gof research on bat coronavirus may have contributed to the current covid-19 pandemic that has devastated the social and economic fabric globally. despite the importance of gof research and the fact that this recent funding has now been suspended by the niaid, one must recognize that accidental escape of engineered pathogens and viruses do pose a catastrophic existential risk for the global human community and every effort must be exercised to prevent (not minimize) this risk. diclosures sr declares no conflicts of interest. ms declares no conflicts of interest. references 1. selgelid, m.j. gain-of-function research: ethical analysis. sci. eng. ethics (2016) 22:923-964. 2. kuo, l., godeke, g. j., raamsman, m. j., masters, p. s., and rottier, p. j. (2000). "retargeting of coronavirus by substitution of the spike glycoprotein ectodomain: crossing the host cell species barrier". journal of virology. 74 (3): 1393-406. 3. imai, m., watanabe, t., hatta, m., et al. (2012). "experimental adaptation of an influenza h5 ha confers respiratory droplet transmission to a reassortant h5 ha/h1n1 virus in ferrets". nature. 486(7403): 420–428. 4. zhang, y., zhang, q., kong, h., et al. (2013). "h5n1 hybrid viruses bearing 2009/h1n1 virus genes transmit in guinea pigs by respiratory droplet". science. 340 (6139): 1459-1463. 5. world health organization coronavirus (covid-19) dashboard. accessed june 08, 2021; 11:53 a.m. central european summer time. https://covid19.who.int/ 6. watkins, m. rand paul and anthony fauci argue over theories about covid-19’s origin. usa today. 2021 may 11. https://news.yahoo.com/rand-paul-anthonyfauci-argue-190133625.html 7. u.s center for disease control and prevention covid19 dashboard. accessed june 08, 2021; 09:22 a.m. central standard time. https://covid.cdc.gov/covid-datatracker/#datatracker-home 8. martin enserink. controversial studies give a deadly flu virus wings. science 02 dec 2011:vol. 334, issue 6060, pp. 1192-1193 9. pavia, a.t. laboratory creation of a highly transmissible h5n1 influenza virus: balancing substantial risks and real benefits. ann int med. 2012 march 20; 156(2): 463-465. 10. news media branch. press statement on the nsabb review of h5n1 research. nih office of the director. 2011 dec 20. https://www.nih.gov/news-events/newsreleases/press-statement-nsabb-review-h5n1-research 11. kaiser, j. lab incidents lead to safety crackdown at cdc. science: news. 2014 july 13. https://www.sciencemag.org/news/2014/07/labincidents-lead-safety-crackdown-cdc 12. u.s. government gain-of-function deliberative process and research funding pause on selected gain-offunction research involving influenza, mers, and sars viruses. https://www.phe.gov/s3/dualuse/documents/gain-offunction.pdf 13. recommendations for the evaluation and oversight of proposed gain-of-function research. 2016. https://web.archive.org/web/20170107112313/https://os p.od.nih.gov/sites/default/files/resources/nsabb_final_ report_recommendations_evaluation_oversight_propo sed_gain_of_function_research.pdf 14. recommended policy guidance for departmental development of review mechanisms for potential pandemic pathogen care and oversight. 2017 jan 9. https://www.phe.gov/s3/dualuse/documents/p3cofinalguidancestatement.pdf 15. collins, f.s. nih lifts funding pause on gain-offunction research. 2017. the nih director. 2017 dec 19. https://www.nih.gov/about-nih/who-we-are/nihdirector/statements/nih-lifts-funding-pause-gainfunction-research. 16. branswell, h. nih awards $7.5 million grant to ecohealth alliance, months after uproar over political interference. stat: in the lab. 2020 aug 27. https://www.statnews.com/2020/08/27/nih-awardsgrant-to-ecohealth-alliance-months-after-uproar-overpolitical-interference/ https://covid19.who.int/ https://news.yahoo.com/rand-paul-anthony-fauci-argue-190133625.html https://news.yahoo.com/rand-paul-anthony-fauci-argue-190133625.html https://covid.cdc.gov/covid-data-tracker/#datatracker-home https://covid.cdc.gov/covid-data-tracker/#datatracker-home https://www.nih.gov/news-events/news-releases/press-statement-nsabb-review-h5n1-research https://www.nih.gov/news-events/news-releases/press-statement-nsabb-review-h5n1-research https://www.sciencemag.org/news/2014/07/lab-incidents-lead-safety-crackdown-cdc https://www.sciencemag.org/news/2014/07/lab-incidents-lead-safety-crackdown-cdc https://www.phe.gov/s3/dualuse/documents/gain-of-function.pdf https://www.phe.gov/s3/dualuse/documents/gain-of-function.pdf https://web.archive.org/web/20170107112313/https:/osp.od.nih.gov/sites/default/files/resources/nsabb_final_report_recommendations_evaluation_oversight_proposed_gain_of_function_research.pdf https://web.archive.org/web/20170107112313/https:/osp.od.nih.gov/sites/default/files/resources/nsabb_final_report_recommendations_evaluation_oversight_proposed_gain_of_function_research.pdf https://web.archive.org/web/20170107112313/https:/osp.od.nih.gov/sites/default/files/resources/nsabb_final_report_recommendations_evaluation_oversight_proposed_gain_of_function_research.pdf https://web.archive.org/web/20170107112313/https:/osp.od.nih.gov/sites/default/files/resources/nsabb_final_report_recommendations_evaluation_oversight_proposed_gain_of_function_research.pdf https://www.phe.gov/s3/dualuse/documents/p3co-finalguidancestatement.pdf https://www.phe.gov/s3/dualuse/documents/p3co-finalguidancestatement.pdf https://www.nih.gov/about-nih/who-we-are/nih-director/statements/nih-lifts-funding-pause-gain-function-research https://www.nih.gov/about-nih/who-we-are/nih-director/statements/nih-lifts-funding-pause-gain-function-research https://www.nih.gov/about-nih/who-we-are/nih-director/statements/nih-lifts-funding-pause-gain-function-research https://www.statnews.com/2020/08/27/nih-awards-grant-to-ecohealth-alliance-months-after-uproar-over-political-interference/ https://www.statnews.com/2020/08/27/nih-awards-grant-to-ecohealth-alliance-months-after-uproar-over-political-interference/ https://www.statnews.com/2020/08/27/nih-awards-grant-to-ecohealth-alliance-months-after-uproar-over-political-interference/ 2021, vol. 1 (s2) 1-2 https://doi.org/10.47488/dhrp.v1is2.12 http://dhrproceedings.org 1 © dhr health institute for research and development editorial is the public outcry for johnson & johnson jansen’s covid-19 vaccine causing blood clots justified? as of today, globally, over 139 million people have been infected with sars-cov-2 virus and over 2.9 million have died as a result of this infection (1). in the united states, over 31 million people have been diagnosed with covid-19, a disease caused by sars-cov-2 virus and over 565,000 people have encountered a fatal outcome. on february 27, 2021, the us food & drug administration (fda) approved the use of johnson & johnson (j&j) jansen covid-19 vaccine for individuals 18 years of age or older under emergency use authorization (2). while the j&j jansen covid-19 vaccine only had 72% efficacy, a single shot of this vaccine was 100% effective in preventing death and hospitalization caused by covid-19 in clinical trials (3). since its approval, it is estimated that over 6.8 million people in the united states have been vaccinated with j&j jansen covid-19 vaccine (4). recent reports have confirmed blood clots in six individuals who have received j&j jansen covid19 vaccine (4). all of these six vaccine recipients were females between the ages of 18 and 48 years; symptoms occurred 6-13 days after vaccination, and all had a previous diagnosis of suffering from thrombocytopenia. the form of blood clotting reported in the recipients of j&j jansen covid-19 vaccine is known as the cerebral venous and sinus thrombosis (cvst), a form of disease only encountered in less than 1% of strokes (5). while it is a rare and severe form of cvst, it is important to recognize that it was only witnessed in 0.000009% of j&j jansen covid-19 vaccine recipients. based on these early reports, on april 13, 2021, both fda and the center for disease control & prevention (cdc) recommended to pause the use of j&j jansen covid-19 vaccine pending further review and to convene a meeting of the advisory committee on immunization practices (acip) to review the available clinical data to make further determination (4). the acip met on april 16, 2021 and recommended to extend the pause to allow for additional review of available clinical data (6). while these precautionary actions are justified, the observed complication following j&j jansen covid-19 vaccination must be viewed in light of the fact that the risk of developing thromboembolism (te) following infection with sars-cov-2 and observed mortality is much higher (7). as reported by malas, et.al, overall arterial te rate in patients with covid-19 was 2% with overall pulmonary embolism rate of 13%. of equal concern is the observation that pooled odds of mortality are 74% higher among patients with te and covid-19 as compared to those without te (7). of note is the fact that the risk of developing blood clots for women of childbearing age using birth control pills is much higher than that observed after vaccination with j&j jansen covid-19 vaccine (8). equally, the risk of blood clots associated with cigarette smoking is higher than that observed after vaccination with j&j jansen covid-19 vaccine (9). while the precautionary measures taken by the cdc and the fda to examine the data in detail is in the best interest of the public, it must be argued that the low risk of blood clot following vaccination with j&j jansen covid-19 vaccine as compared to that following infection with sars-cov-2 may justify its continued use to vaccinate people as a means to prevent infection and subsequent hospitalization. references 1. covid-19 dashboard by the center for systems science and engineering at johns hopkins university. april 16, 2021; 12:01 pm cst. https://coronavirus.jhu.edu/map.html 2. letter of emergency use authorization from rear admiral denise m. hinton to janssen biotech, inc., dated february 27, 2021. https://www.fda.gov/media/146303/download 3. vaccines and related biological products advisory committee meeting february 26, 2021. fda briefing document janssen https://coronavirus.jhu.edu/map.html https://www.fda.gov/media/146303/download dhrp, 2021, vol. 1 (s2) 1-2 editorial http://dhrproceedings.org 2 © dhr health institute for research and development ad26.cov2.s vaccine for the prevention of covid-19. https://www.fda.gov/media/146217/download 4. joint cdc and fda statement on johnson & johnson covid19 vaccine. https://www.fda.gov/news-events/pressannouncements/joint-cdc-and-fda-statement-johnson-johnsoncovid-19-vaccine 5. masuhr f, einhäupl k. treatment of cerebral venous and sinus thrombosis. front neurol neurosci. 2008;23:132-43. doi: 10.1159/000111375. pmid: 18004059. 6. cdc recommendation to pause use of johnson & johnson’s janssen covid-19 vaccine. https://www.cdc.gov/coronavirus/2019ncov/vaccines/safety/jjupdate.html 7. malas bm, naazie, ih, et.al. thromboembolism risk of covid-19 is high and associated with a higher risk of mortality: a systematic review and meta-analysis. eclinicalmedicine. 2020; 29-30. doi: https://doi.org/10.1016/j.eclinm.2020.100639 8. sidney s, cheetham tc, et.al. recent combined hormonal contraceptives (chcs) and the risk of thromboembolism and other cardiovascular events in new users. contraception. 2013 jan;87(1):93-100. doi: 10.1016/j.contraception.2012.09.015. epub 2012 oct 19. pmid: 23083525. 9. cheng y-j, liu z-h, yao f-j, zeng w-t, zheng d-d, dong yg, et al. (2013) current and former smoking and risk for venous thromboembolism: a systematic review and metaanalysis. plos med 10(9): e1001515. https://doi.org/10.1371/journal.pmed.1001515 sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 https://www.fda.gov/media/146217/download https://www.fda.gov/news-events/press-announcements/joint-cdc-and-fda-statement-johnson-johnson-covid-19-vaccine https://www.fda.gov/news-events/press-announcements/joint-cdc-and-fda-statement-johnson-johnson-covid-19-vaccine https://www.fda.gov/news-events/press-announcements/joint-cdc-and-fda-statement-johnson-johnson-covid-19-vaccine https://doi.org/10.1159/000111375 https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/jjupdate.html https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/jjupdate.html https://doi.org/10.1016/j.eclinm.2020.100639 https://doi.org/10.1371/journal.pmed.1001515 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 122 2022, vol. 2 no. s2 122-132 commentary breast cancer in hispanic women america escalona1,2, jaraeth garza1,3, isabella larralde1,3, gabriella martinez1,4, mia muñoz1,3, darleny reyes1,2, ryan villalobos1,2, kassandra zuniga1,3 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2progreso early college high school, progreso, tx 3san benito high school, san benito, tx 4robert vela high school, edinburg, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 08/05/2022 accepted for publication 8/16/2022 published 8/16/2022 keywords: breast cancer; treatment breast cancer; cancer hispanic women introduction breast cancer is one of the most common cancers in women (1). it is also the second most common cause of death for females (2). in the united states, there are about 287,850 women diagnosed with breast cancer every year (3). most women are diagnosed when they are 50 years or older (4). although it is more likely for older women to be diagnosed, younger women can be at risk of it as well (2). hispanic women are more likely to be diagnosed at a younger age and more likely to die from breast cancer (5). pathogenesis breast cancers are often a type of carcinoma called an adenocarcinoma. by definition, breast cancer is a disease in which cells in the breast grow out of control often leaving a “lump” in the breasts (6). genetics between 5% to 10% of breast cancer cases are hereditary. this means the cancer results directly from gene changes or mutations passed on from a parent (7). the mutated genes that are often responsible for cancer are the brca1 and brca2 genes. brca1 and brca2 are tumor suppressing genes that contain the instructions for the protein responsible for reparation of damaged dna, meaning they are the genes responsible for fighting cancer (8). when these genes are working normally, they keep cancer cells from growing and dividing too rapidly or uncontrollably. however, when these genes are mutated, they are not able to do their job properly. as a result, damaged dna that is left unrepaired by the mutated genes may cause the accumulation of cellular mutations that are likely to divide and change rapidly which can cause cancer (9). not every woman with mutated brca1 and brca2 genes will get breast cancer, but they are at an increased risk. escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 123 2022, vol. 2 no. s2 122-132 figure 1. cancer risk associated with inherited brca2 mutations reference: https://www.facingourrisk.org/info/hereditary-cancer-andgenetic-testing/hereditary-cancer-genes-and-risk/genes-byname/brca2/cancer-risk diagnosis diagnosing patients with breast cancer can be difficult to do as there is a process that has to be done before they are able to diagnose. there are machines that are used to screen for cancer as well as locate the site of the cancer. it may also be used to determine how the cancer has developed. to visualize internal breast structures, a low dose x-ray of the breast is performed; this procedure is known as mammography. it is one of the most suitable techniques to detect breast cancer (6). there are two most common methods used to diagnose which are known as learning machine and deep learning. machine learning goes with a small group in simplified words and is used to help or improve research. deep learning has the same process and steps but in machine learning it is separated and taken slow (6, 10). figure 2. difference between two pipelines: conventional machine learning pipeline (left) and deep learning pipeline (right) reference: gardezi sjs, elazab a, lei b, wang t. breast cancer detection and diagnosis using mammographic data: systematic review. j med internet res. 2019 jul 26;21(7):e14464. doi: 10.2196/14464. pmid: 31350843; pmcid: pmc6688437. there are chances of a false positive and false negative due to background noise, unwanted/ unnecessary objects, annotations, and even labels. the process can be somewhat complex due to many steps in a single process, which can be considered as sub-groups of one process, but have to go through several steps to determine the diagnosis. with that being said the process is time consuming not only that but a vast amount of money just to process and identify to then treat the cancer which can be a great amount of money. for example, the minority populations/ ethnicity/ race can be affected by said process and money such as the poor low economic race such as the hispanics. in research it is said that the hispanic/ latinos are what make the most population of patients that have breast cancer (11). hispanics are known to take long in the process or not even do the entire steps before it is too late therefore the cancer has spread into more than the breast into muscles surrounding the tissue. in most cases there is a low chance of surviving the cancer as it may be too late. ethnicity/race breast cancer is one of the most common cancers affecting young women. in hispanic/latina women, it is the leading cause of cancer death (13). https://www.facingourrisk.org/info/hereditary-cancer-and-genetic-testing/hereditary-cancer-genes-and-risk/genes-by-name/brca2/cancer-risk https://www.facingourrisk.org/info/hereditary-cancer-and-genetic-testing/hereditary-cancer-genes-and-risk/genes-by-name/brca2/cancer-risk https://www.facingourrisk.org/info/hereditary-cancer-and-genetic-testing/hereditary-cancer-genes-and-risk/genes-by-name/brca2/cancer-risk escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 124 2022, vol. 2 no. s2 122-132 there are many components that contribute to this. some are culture, genetics, and more. regarding the hispanic culture, there are many factors that contribute to increased cases of breast cancer, such as diabetes and obesity (15). one example is the diet in the culture. food is very important in the culture and while it’s not always a factor, the diet and overall lifestyle habits of hispanic people, specifically in the us, is not always the healthiest, and it can contribute to developing diseases like diabetes and obesity (14). having diseases like diabetes and obesity may lead to developing breast cancer and/or developing a more severe case than they would have otherwise (15). another risk factor in the culture is the mindset. there is a relatively common apprehension for seeking medical care within the community. lack of education may contribute to this, depending on the area. delay in seeking medical care increases the progression and severity of other diseases in hispanic women, which can increase the risk of having breast cancer. there can also be a language barrier that contributes to this mindset. the patient may feel uncomfortable being in an environment where they don’t fully understand everything that’s going on, and they may not feel understood themselves (16). this also contributes to cases of cancer potentially being caught too late, or the patient not getting adequate care for their sickness. there are also economic disparities that can impact the treatment of hispanic women with breast cancer. it is very common in the hispanic culture to find a family with one or more parents who work multiple jobs or work one very long and stressful job, only to be able to make ends meet (17). adequate cancer treatment can be very expensive and may not be available in the patient's community, so they may have to travel to get this care. this is not always an option, and this can negatively impact the treatment. another very common barrier that people in the community may face is lack of health insurance, which can also be a reason for not going to see a medical provider or getting adequate care (18). a further barrier that some hispanic/latina women face is documentation. in the us, it is extremely difficult for an undocumented individual to get the same treatment as someone that is documented. being undocumented can intensify some of the previously mentioned factors such as economic disparities, being uninsured, not being able to freely travel to seek specialized care, and mindset (19). ultimately, a family may just choose to simply not go through all of the hardships that come with breast cancer treatment, (financial, psychosocial, physical, etc.) especially if there is no guarantee that it will work. age comparison women get breast cancer usually after they turn 65 years old (20). most new cases in the united states are shown to all be older than 65 years old. although breast cancer in younger women is not unknown, it is rare because breast cancer only affects about 4-6 % of the women under the age of 45 (21). breast cancer in younger women has a more aggressive effect than the patients who are older (21) they usually have a worse prognosis and more aggressive phenotype; higher proportions of highgrade and later-stage tumors; and lower estrogen receptor positivity (21) there have also been cases of women with breast cancer of the age of 80 and older. the older the patients, the more risk and life threatening factors there are. the quality of life is retained from any treatment they may receive (22). the women in their mid 50’s to late 60’s have very low risk compared to the women who are younger or older than those ages (23). risk factors there are many risk factors to getting breast cancer such as smoking, and obesity. studies have shown that women that smoke at adolescent or perimenarcheal ages are at a high risk (24). a study showed that out of 102,927 women with 7.7 years follow-up, 1,815 developed breast cancer (24). obesity is a higher risk for developing breast cancer, particularly in postmenopausal women, and with worse disease outcome for women of all ages. obesity is associated with the risk of both preand postmenopausal breast cancer (25). many things such as body mass index, weight gain and waist, and hip ratio have all been positively associated with risk of developing breast cancer (25). if you were to drink escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 125 2022, vol. 2 no. s2 122-132 three alcoholic drinks per week you would be 15% more likely to contract breast cancer (26). experts conclude that for every extra drink your percentage will increase by 10% (26). women who breastfeed for at least one month had a 50-58% chance, and women with at least 2 children had an 87-93% (27). there are many risk factors to contracting breast cancer, many that you have control over, but there are few that we do. therefore, people should be proactive and choose a healthier lifestyle to better their chances of improving their quality of life. side effects women diagnosed with breast cancer are in need of information regarding the treatments and side effects of breast cancer. there are many side effects during the different stages of breast cancer. when someone that is a young adult and diagnosed with breast cancer, they run the risk of several complications such as blood clots, sexual difficulties, and infertility (28). breast cancer (bc) in young women is rare, affecting only 4-6% of women under the age of 40 (29) regardless, breast cancer remains the most common malignancy among younger patients. recently, a significant increase in bc rates has been observed among pre-menopausal subjects (30). breast cancer in young women requires special attention due to its specific morphologic and prognostic characteristics and unique aspects, including fertility preservation and psychosocial issues. if an older person is diagnosed with breast cancer, they are more likely to run more of a risk of infection due to their immune system (30). the side effects include menopause, lymphedema, heart problems, and dental issues. compared to other ethnicities, the hispanic/latino community runs more of a risk of getting diagnosed with breast cancer in women over other ethnicities such as white and nonhispanic (31). since many women suffer from breast cancer they often have to go through treatments that may leave them with both short-term and long-term side effects due to the therapy they go through. all though breast cancer is a serious topic to deal with, many women may get concerned about the sexual difficulties they may go through. additionally, it may be difficult to talk to their physician about the way this could affect them or their partner (32). some may not see what women are going through such as self-image dysmorphia or sexuality concerns. this can cause a person that is diagnosed with breast cancer or has breast cancer to start negatively hating the way they feel because they are dissatisfied with the way they look due to the way they think of themselves (33). they may also believe that they themselves as a person are not sexually appealing and begin to be selfconscious about their surgical scars and texture of their skin. all of these issues are side effects of breast cancer a woman can or has suffered through. an important factor to consider with both surgical options and medication used to treat cancer is the side effects and to be proactive in the positive outcomes depending on what is recommended to the patient. side effects include both physical and physiological changes. “expected physical changes include hair loss, breast or chest wall disfigurement, skin texture change, vaginal irritation, decreased bone density, hot flashes, and weight loss or gain.” (34). diagnosis and treatments are an enormous change in a patient’s life. there are many side effects and issues that can happen. there will be various changes in your diet, day-to-day life, muscle deterioration, and depression. once you start your journey you will notice that you may not be able to keep certain foods down, and will have a lot of regurgitation. your taste buds will most likely not like a vast variety of food but you can always get meal supplements to keep your food intake up. ongoing trials test that the impact of weight loss and lifestyle changes can decrease the risk of secondary breast cancer. on another note your taste buds aren't the only things that change, your muscle mass will defer since you may not want to be mobile anymore due to soreness/pain from your treatments. on average, 25% lower strength was found in lower extremities and 1216% in the upper extremities (35). your doctor or oncologist will refer you to a physical therapist to keep muscles and nervous system working. since you will be going to a lot of treatments and therapies/appointments, you will notice that you may not have the time or energy to see family/friends. there is a 38.2% chance of getting depression and 32.3% of anxiety (36). any cancer patient is at risk for escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 126 2022, vol. 2 no. s2 122-132 depression but breast cancer patients are at a higher risk. it is good to have a stable support system at home during these tough times, especially to help with mobility, diet, and emotional struggles. treatment chemotherapy is a common breast cancer treatment. there were significant racial/ethnic differences in the quality of life controlling for socio demographics, clinical factors and treatment factors. treatment depends on the stage of cancer. it may consist of chemotherapy, radiation, and surgery. usually, you receive chemotherapy in two to three week cycles, with periods of rest between cycles. many hispanic women take action on complementary interventions during their breast cancer treatment and set out the association between the oppressive side effects and the most common side effects. some of the side effects can be hair loss, nail changes, mouth sores, loss of appetite or weight changes, nausea and vomiting, diarrhea, fatigue, hot flashes and/or vaginal dryness from menopause caused by chemotherapy and nerve damage (37). the side effects normally go away once the treatment is done; there are always ways to reduce these side effects. there may be some racial/ethnic differences in the effectiveness of some of the treatments for breast cancer that have not been fully understood (38). the chemotherapy for breast cancer can cause side effects, depending on the type and dose given, and the length of the treatment. hispanic women are more likely to be diagnosed at a later stage and get less aggressive therapy. that leads to a lower survival rate. alternative treatment options treatment options for breast cancer (bc) can range from conservative methods to more aggressive approaches based on the stage of breast cancer. cancer patients can also opt for chemotherapy, biological therapy and even hormone therapy. other options include partial mastectomy (pm), mastectomy without reconstruction (m), mastectomy with reconstruction (m+r) and pm with oncoplastic reconstruction (os). treatment options can range from invasive to noninvasive procedures and medication patient’s dependent on the stage in which cancer was detected. hormone levels are also an important factor to consider when looking into therapy. table 1 illustrates the typical treatment options for breast cancer. time is another factor. both in when it is diagnosed and how much time the patient will be in treatment. in addition to considering time invested in treatment options patients need to also consider what medications they will be taking. table 2 indicates the medications used in the treatment of breast cancer. treatment options along with recommendation for medication can be discussed with the patient's oncologist to determine the best possible option to successfully treat the patient. in addition, it is important to consider what treatment option the patient will pick to prevent a recurrence as much as possible. treatment cost the yearly cost of breast cancer treatment in the united states is $16.5 billion according to the cdc (39). it is also said to have the highest cost for treatment amongst cancers (39). the cost of treatment can differ depending on many things like what stage the cancer is in, the type of treatment you’ll receive, age, and if you have insurance or not. the typical patient can expect to pay from $60,637-$134,682 for treatment although this can vary (40). depending on the type of treatment, a stage 4 patient could expect to pay up to 64% more than patients with lower stages of breast cancer (40). in patients undergoing a surgical removal, those with stage 0 patients can expect to pay 121% more than stage 4 patients (40). since breast cancer in younger women tends to be more aggressive, the treatment is usually more intensive and expensive (41). treatment is expensive with or without insurance, however, a patient is likely to pay more without it. fortunately, there are multiple organizations who offer help to patients (42). some of these organizations include the healthwell foundation, partnership for prescription assistance, and the pink fund (43). some of these foundations escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 127 2022, vol. 2 no. s2 122-132 can also provide support for those that have insurance but do not cover individual drugs or certain treatments. conclusion the consequences of breast cancer include not only different occurrences during treatment, but also diagnosis. breast cancer is most common in hispanic women, making up more than half of the population of hispanic women. during the early years of mammography, there were many new cases of cancer in situ, but 75% of the cases died due to cancer in situ. thanks to the advancements in cancer treatment methods, the quality of life for cancer patients has greatly improved. furthermore, there is still a need to change the rate. hispanic women are more likely than non-hispanic women to be affected by this breast cancer. it is due to poor living/economic options that hispanics and latinos are the most affected. the hispanics had scarce or no resources compared to other races. in spite of this, many hispanics do not seek medical attention until they are too ill or have a condition. this in turn means that the disease or cancer has spread to other parts of the body. poor economic sources are one possibility, which can greatly impact the entire community, thus contributing to the large breast cancer population. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected and region one esc paths references 1. ben-dror j, shalamov m, sonnenblick a. the history of early breast cancer treatment. genes (basel). 2022 may 27;13(6):960. doi: 10.3390/genes13060960. pmid: 35741721; pmcid: pmc9222657. 2. medical costs associated with metastatic breast cancer in younger, midlife, and older women. (n.d.). retrieved august 3, 2022, from https://link.springer.com/epdf/10.1007/s105 49-020-05654x?sharing_token=ennpg7dhcm4xn5hwop pmafe4rwlqnchnbyi7wbcmay6g4bjm m1wszz04bmgdxidn6up8qzo5i09t4r_m ttnmk1bezwptcb5bki8sy5nkd6bbrjg4kr6m4tjwhzku fg8__yczxc3izk4rnysgyn0uwsskgx1rbkit3jczjnbvi %3d 3. breast cancer statistics: how common is breast cancer? american cancer society. (n.d.). retrieved august 3, 2022, from https://www.cancer.org/cancer/breastcancer/about/how-common-is-breastcancer.html#:~:text=about%20287%2c850 %20new%20cases%20of,will%20die%20fro m%20breast%20cancer. 4. centers for disease control and prevention. (2021, september 20). what are the risk factors for breast cancer? centers for disease control and prevention. retrieved august 3, 2022, from https://www.cdc.gov/cancer/breast/basic_inf o/risk_factors.htm#:~:text=most%20breast %20cancers%20are%20found,factors%20ha ve%20the%20same%20effect. 5. bcrf. (2022, january 11). what hispanic women and latinas need to know about breast cancer. breast cancer research foundation. retrieved august 2, 2022, from https://www.bcrf.org/blog/hispanic-latinabreast-cancer-facts-statistics/ 6. centers for disease control and prevention. (2021, september 22). what is breast cancer? centers for disease control and prevention. retrieved august 2, 2022, from https://www.cdc.gov/cancer/breast/basic_inf o/what-is-breast-cancer.htm 7. breast cancer risk factors you can't change. american cancer society. (n.d.). retrieved august 2, 2022, from https://www.cancer.org/cancer/breastcancer/risk-and-prevention/breast-cancerrisk-factors-you-cannothttps://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://link.springer.com/epdf/10.1007/s10549-020-05654-x?sharing_token=ennpg7dhcm4xn5hwoppmafe4rwlqnchnbyi7wbcmay6g4bjmm1wszz04bmgdxidn6up8qzo5i09t4r_mttnmk1bezwp-tcb5bki8sy5nkd6bbrjg4kr6m4tjwhzkufg8__yczxc3iz-k4rnysgyn0uwsskgx1rbkit3jczjnbvi%3d https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html#:~:text=about%20287%2c850%20new%20cases%20of,will%20die%20from%20breast%20cancer https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html#:~:text=about%20287%2c850%20new%20cases%20of,will%20die%20from%20breast%20cancer https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html#:~:text=about%20287%2c850%20new%20cases%20of,will%20die%20from%20breast%20cancer https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html#:~:text=about%20287%2c850%20new%20cases%20of,will%20die%20from%20breast%20cancer https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html#:~:text=about%20287%2c850%20new%20cases%20of,will%20die%20from%20breast%20cancer https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html#:~:text=about%20287%2c850%20new%20cases%20of,will%20die%20from%20breast%20cancer https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html#:~:text=about%20287%2c850%20new%20cases%20of,will%20die%20from%20breast%20cancer https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm#:~:text=most%20breast%20cancers%20are%20found,factors%20have%20the%20same%20effect https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm#:~:text=most%20breast%20cancers%20are%20found,factors%20have%20the%20same%20effect https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm#:~:text=most%20breast%20cancers%20are%20found,factors%20have%20the%20same%20effect https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm#:~:text=most%20breast%20cancers%20are%20found,factors%20have%20the%20same%20effect https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm#:~:text=most%20breast%20cancers%20are%20found,factors%20have%20the%20same%20effect https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm#:~:text=most%20breast%20cancers%20are%20found,factors%20have%20the%20same%20effect https://www.bcrf.org/blog/hispanic-latina-breast-cancer-facts-statistics/ https://www.bcrf.org/blog/hispanic-latina-breast-cancer-facts-statistics/ https://www.bcrf.org/blog/hispanic-latina-breast-cancer-facts-statistics/ https://www.bcrf.org/blog/hispanic-latina-breast-cancer-facts-statistics/ escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 128 2022, vol. 2 no. s2 122-132 change.html#:~:text=having%20a%20first %2ddegree%20relative,higher%20risk%20 of%20breast%20cancer. 8. centers for disease control and prevention. (2021, september 27). hereditary breast cancer and brca genes. centers for disease control and prevention. retrieved august 2, 2022, from https://www.cdc.gov/cancer/breast/young_w omen/bringyourbrave/hereditary_breast_can cer/ 9. centers for disease control and prevention. (2021, september 27). brca gene mutations. centers for disease control and prevention. retrieved august 3, 2022, from https://www.cdc.gov/cancer/breast/young_w omen/bringyourbrave/hereditary_breast_can cer/brca_gene_mutations.htm 10. gardezi sjs, elazab a, lei b, wang t. breast cancer detection and diagnosis using mammographic data: systematic review. j med internet res. 2019 jul 26;21(7):e14464. doi: 10.2196/14464. pmid: 31350843; pmcid: pmc6688437. 11. radecka b, litwiniuk m. breast cancer in young women. ginekol pol. 2016;87(9):659663. doi: 10.5603/gp.2016.0062. pmid: 27723074. 12. romero-cordoba sl, salido-guadarrama i, rebollar-vega r, bautista-piña v, dominguez-reyes c, tenorio-torres a, villegas-carlos f, fernández-lópez jc, uribe-figueroa l, alfaro-ruiz l, hidalgomiranda a. comprehensive omic characterization of breast cancer in mexicanhispanic women. nat commun. 2021 apr 14;12(1):2245. doi: 10.1038/s41467-02122478-5. pmid: 33854067; pmcid: pmc8046804. 13. nahleh z, botrus g, dwivedi a, badri n, otoukesh s, diab n, biswas s, jennings m, elzamly s. clinico-pathologic disparities of breast cancer in hispanic/latina women. breast dis. 2018;37(3):147-154. doi: 10.3233/bd-170309. pmid: 29376844. 14. albrecht, s. (2021, october 11). concerning dietary patterns among latinx linked to years living in. search the website. retrieved august 3, 2022, from https://www.publichealth.columbia.edu/publ ic-health-now/news/concerning-dietarypatterns-among-latinx-linked-years-living-us 15. jaiswal p, tripathi v, nayak a, kataria s, lukashevich v, das ak, parmar hs. a molecular link between diabetes and breast cancer: therapeutic potential of repurposing incretin-based therapies for breast cancer. curr cancer drug targets. 2021;21(10):829-848. doi: 10.2174/1568009621666210901101851. pmid: 34468298. 16. machado, a. (2014, may 7). why many latinos dread going to the doctor. the atlantic. retrieved august 3, 2022, from https://www.theatlantic.com/health/archive/ 2014/05/why-many-latinos-dread-going-tothe-doctor/361547/ 17. wildsmith, e., ramos-olazagasti, m. a., alvira-hammond, m., chen, y., cabrera, n., &amp; finno-velasquez, m. (2020, february 18). the job characteristics of low-income hispanic parents. hispanic research center. retrieved august 3, 2022, from https://www.hispanicresearchcenter.org/rese arch-resources/the-job-characteristics-oflow-income-hispanic-parents/ 18. artiga, s., tolbert, j., &amp; orgera, k. (2020, november 6). hispanic people are facing widening gaps in health coverage. kff. retrieved august 3, 2022, from https://www.kff.org/policy-watch/hispanicpeople-facing-widening-gaps-healthcoverage/ 19. beck tl, le tk, henry-okafor q, shah mk. medical care for undocumented immigrants: national and international issues. physician assist clin. 2019 jan;4(1):33-45. doi: 10.1016/j.cpha.2018.08.002. epub 2018 nov 16. pmid: 32289088; pmcid: pmc7141175. 20. muss hb. factors used to select adjuvant therapy of breast cancer in the united states: an overview of age, race, and socioeconomic status. j natl cancer inst monogr. 2001;(30):52-5. doi: 10.1093/oxfordjournals.jncimonographs.a00 3461. pmid: 11773292 https://www.cdc.gov/cancer/breast/young_women/bringyourbrave/hereditary_breast_cancer/ https://www.cdc.gov/cancer/breast/young_women/bringyourbrave/hereditary_breast_cancer/ https://www.cdc.gov/cancer/breast/young_women/bringyourbrave/hereditary_breast_cancer/ https://www.publichealth.columbia.edu/public-health-now/news/concerning-dietary-patterns-among-latinx-linked-years-living-us https://www.publichealth.columbia.edu/public-health-now/news/concerning-dietary-patterns-among-latinx-linked-years-living-us https://www.publichealth.columbia.edu/public-health-now/news/concerning-dietary-patterns-among-latinx-linked-years-living-us https://www.theatlantic.com/health/archive/2014/05/why-many-latinos-dread-going-to-the-doctor/361547/ https://www.theatlantic.com/health/archive/2014/05/why-many-latinos-dread-going-to-the-doctor/361547/ https://www.theatlantic.com/health/archive/2014/05/why-many-latinos-dread-going-to-the-doctor/361547/ https://www.hispanicresearchcenter.org/research-resources/the-job-characteristics-of-low-income-hispanic-parents/ https://www.hispanicresearchcenter.org/research-resources/the-job-characteristics-of-low-income-hispanic-parents/ https://www.hispanicresearchcenter.org/research-resources/the-job-characteristics-of-low-income-hispanic-parents/ https://www.kff.org/policy-watch/hispanic-people-facing-widening-gaps-health-coverage/ https://www.kff.org/policy-watch/hispanic-people-facing-widening-gaps-health-coverage/ https://www.kff.org/policy-watch/hispanic-people-facing-widening-gaps-health-coverage/ escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 129 2022, vol. 2 no. s2 122-132 21. tichy jr, lim e, anders ck. breast cancer in adolescents and young adults: a review with a focus on biology. j natl compr canc netw. 2013 sep 1;11(9):1060-9. doi: 10.6004/jnccn.2013.0128. pmid: 24029122. 22. shachar ss, hurria a, muss hb. breast cancer in women older than 80 years. j oncol pract. 2016 feb;12(2):123-32. doi: 10.1200/jop.2015.010207. pmid: 26869650. 23. hill da, friend s, lomo l, wiggins c, barry m, prossnitz e, royce m. breast cancer survival, survival disparities, and guidelinebased treatment. breast cancer res treat. 2018 jul;170(2):405-414. doi: 10.1007/s10549-018-4761-7. epub 2018 mar 22. pmid: 29569018; pmcid: pmc6002943. https://pubmed.ncbi.nlm.nih.gov/29569018/ 24. jones, m. e., schoemaker, m. j., wright, l. b., ashworth, a., & swerdlow, a. j. (2017). smoking and risk of breast cancer in the generations study cohort. breast cancer research: bcr, 19(1), 118. https://doi.org/10.1186/s13058-017-0908-4 25. carmichael a. r. (2006). obesity and prognosis of breast cancer. obesity reviews : an official journal of the international association for the study of obesity, 7(4), 333–340. https://doi.org/10.1111/j.1467789x.2006.00261.x 26. drinking alcohol. (n.d.). retrieved august 2, 2022, from https://www.breastcancer.org/risk/riskfactors/drinking-alcohol 27. yaghjyan, l., austin-datta, r. j., oh, h., heng, y. j., vellal, a. d., sirinukunwattana, k., baker, g. m., collins, l. c., murthy, d., rosner, b., & tamimi, r. m. (2021). associations of reproductive breast cancer risk factors with breast tissue composition. breast cancer research : bcr, 23(1), 70. https://doi.org/10.1186/s13058-021-01447-2 28. ekwueme du, allaire bt, guy gp jr, arnold s, trogdon jg. treatment costs of breast cancer among younger women aged 19-44 years enrolled in medicaid. am j prev med. 2016 feb;50(2):278-85. doi: 10.1016/j.amepre.2015.10.017. pmid: 26775907; pmcid: pmc5860800 29. hale mj, howell a, dowsett m, cuzick j, sestak i. tamoxifen related side effects and their impact on breast cancer incidence: a retrospective analysis of the randomized ibis-i trial. breast. 2020 dec;54:216-221. doi: 10.1016/j.breast.2020.10.015. epub 2020 oct 31. pmid: 33160147; pmcid: pmc7649356 30. johnson rh, anders ck, litton jk, ruddy kj, bleyer a. breast cancer in adolescents and young adults. pediatr blood cancer. 2018 dec;65(12):e27397. doi: 10.1002/pbc.27397. epub 2018 aug 28. pmid: 30156052; pmcid: pmc6192832 31. yedjou cg, sims jn, miele l, noubissi f, lowe l, fonseca dd, alo ra, payton m, tchounwou pb. health and racial disparity in breast cancer. adv exp med biol. 2019;1152:31-49. doi: 10.1007/978-3-03020301-6_3. pmid: 31456178; pmcid: pmc6941147 32. hungr c, sanchez-varela v, bober sl. selfimage and sexuality issues among young women with breast cancer: practical recommendations. rev invest clin. 2017 mar-apr;69(2):114-22. doi: 10.24875/ric.17002200. pmid: 28453509 33. reese jb, beach mc, smith kc, bantug et, casale ke, porter ls, bober sl, tulsky ja, daly mb, lepore sj. effective patientprovider communication about sexual concerns in breast cancer: a qualitative study. support care cancer. 2017 oct;25(10):31993207. doi: 10.1007/s00520-017-3729-1. epub 2017 apr 27. pmid: 28451911; pmcid: pmc5803445 34. maughan, k. l., lutterbie, m. a., & ham, p. s. (2010). treatment of breast cancer. american family physician, 81(11), 1339– 1346. 35. klassen, o., schmidt, m. e., ulrich, c. m., schneeweiss, a., potthoff, k., steindorf, k., & wiskemann, j. (2017). muscle strength in breast cancer patients receiving different treatment regimes. journal of cachexia, https://pubmed.ncbi.nlm.nih.gov/29569018/ https://pubmed.ncbi.nlm.nih.gov/29569018/ https://doi.org/10.1186/s13058-017-0908-4 https://doi.org/10.1111/j.1467-789x.2006.00261.x https://doi.org/10.1111/j.1467-789x.2006.00261.x https://www.breastcancer.org/risk/risk-factors/drinking-alcohol https://www.breastcancer.org/risk/risk-factors/drinking-alcohol https://www.breastcancer.org/risk/risk-factors/drinking-alcohol https://www.breastcancer.org/risk/risk-factors/drinking-alcohol https://doi.org/10.1186/s13058-021-01447-2 escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 130 2022, vol. 2 no. s2 122-132 sarcopenia and muscle, 8(2), 305–316. https://doi.org/10.1002/jcsm.12165 36. tsaras, k., papathanasiou, i. v., mitsi, d., veneti, a., kelesi, m., zyga, s., & fradelos, e. c. (2018). assessment of depression and anxiety in breast cancer patients: prevalence and associated factors. asian pacific journal of cancer prevention: apjcp, 19(6), 1661–1669. https://doi.org/10.22034/apjcp.2018.19.6.1 661 37. chemotherapy for breast cancer: breast cancer treatment. american cancer society. (n.d.). retrieved august 4, 2022, from https://www.cancer.org/cancer/breastcancer/treatment/chemotherapy-for-breastcancer.html 38. ma sj, serra lm, yu b, farrugia mk, lovoli aj, yu h, yao s, oladeru ot, singh ak racial/ethnic differences and trends in pathologic complete response following neoadjuvant chemotherapy for breast cancer. cancers (basel). 2022 jan 21;14(3):534. doi :10.3390/cancers 14030534. pmid: 35158802; pmcid: pmc8833599. 39. centers for disease control and prevention. (2021, august 18). cost-effectiveness of breast cancer interventions. centers for disease control and prevention. retrieved august 2, 2022, from https://www.cdc.gov/chronicdisease/progra ms-impact/pop/breastcancer.htm#:~:text=%2416.5%20billion &amp;text=13%25%20of%20all%20cancer %20treatment,states%20are%20for%20brea st%20cancer.&amp;text=breast%20cancer %20has%20the%20highest%20treatment%2 0cost%20of%20any%20cancer.&amp;text= the%20amount%20that%20patients%20pay ,widely%20depending%20on%20insurance %20coverage. 40. price, s. (2022, march 1). stage 4 breast cancer treatment &amp; chemo costs top $130,000. valuepenguin. retrieved august 2, 2022, from https://www.valuepenguin.com/healthinsurance-breast-cancer-treatment-study 41. ekwueme du, allaire bt, guy gp jr, arnold s, trogdon jg. treatment costs of breast cancer among younger women aged 19-44 years enrolled in medicaid. am j prev med. 2016 feb;50(2):278-85. doi: 10.1016/j.amepre.2015.10.017. pmid: 26775907; pmcid: pmc5860800. 42. covering the costs of your breast cancer care. (n.d.). retrieved august 3, 2022, from https://www.breastcancer.org/managinglife/covering-cost-of-care 43. financial assistance programs for young women with breast cancer. young survival coalition, young women facing breast cancer together. (n.d.). retrieved august 4, 2022, from https://www.youngsurvival.org/learn/livingwith-breast-cancer/practicalconcerns/financial-assistance https://doi.org/10.22034/apjcp.2018.19.6.1661 https://doi.org/10.22034/apjcp.2018.19.6.1661 https://www.cancer.org/cancer/breast-cancer/treatment/chemotherapy-for-breast-cancer.html https://www.cancer.org/cancer/breast-cancer/treatment/chemotherapy-for-breast-cancer.html https://www.cancer.org/cancer/breast-cancer/treatment/chemotherapy-for-breast-cancer.html https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.cdc.gov/chronicdisease/programs-impact/pop/breast-cancer.htm#:~:text=%2416.5%20billion&amp;text=13%25%20of%20all%20cancer%20treatment,states%20are%20for%20breast%20cancer.&amp;text=breast%20cancer%20has%20the%20highest%20treatment%20cost%20of%20any%20cancer.&amp;text=the%20amount%20that%20patients%20pay,widely%20de https://www.valuepenguin.com/health-insurance-breast-cancer-treatment-study https://www.valuepenguin.com/health-insurance-breast-cancer-treatment-study https://www.valuepenguin.com/health-insurance-breast-cancer-treatment-study https://www.valuepenguin.com/health-insurance-breast-cancer-treatment-study https://www.breastcancer.org/managing-life/covering-cost-of-care https://www.breastcancer.org/managing-life/covering-cost-of-care https://www.breastcancer.org/managing-life/covering-cost-of-care https://www.breastcancer.org/managing-life/covering-cost-of-care https://www.youngsurvival.org/learn/living-with-breast-cancer/practical-concerns/financial-assistance https://www.youngsurvival.org/learn/living-with-breast-cancer/practical-concerns/financial-assistance https://www.youngsurvival.org/learn/living-with-breast-cancer/practical-concerns/financial-assistance https://www.youngsurvival.org/learn/living-with-breast-cancer/practical-concerns/financial-assistance https://www.youngsurvival.org/learn/living-with-breast-cancer/practical-concerns/financial-assistance escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 131 2022, vol. 2 no. s2 122-132 table 1: typical treatment options for breast cancer by stage reference: maughan, k. l., lutterbie, m. a., & ham, p. s. (2010). treatment of breast cancer. american family physician, 81(11), 1339–1346. (34) escalona, et al breast cancer in women https://doi.org/10.47488/dhrp.v2is2.73 dhr proceedings ǀ http://dhrproceedings.org 132 2022, vol. 2 no. s2 122-132 table 2: medication used in the treatment of breast cancer reference: maughan, k. l., lutterbie, m. a., & ham, p. s. (2010). treatment of breast cancer. american family physician, 81(11), 1339–1346. (38) 2021, vol. 1 (s4) 20-21 https://doi.org/10.47488/dhrp.v1is4.29 http://dhrproceedings.org 20 © dhr health institute for research and development editorial will molnupiravir be the first oral treatment for high-risk nonhospitalized patients with mild-moderate covid-19? the first case of sars-cov-2 infection in united states was confirmed on january 19, 2020, in a man who had returned home to snohomish county, washington on january 15, 2020, after traveling to wuhan, china. since the outbreak of this pandemic, significant progress has been made in the development of vaccines that are used in preventing sars-cov-2 infection. to date, over 392 million doses of the three vaccines approved under the emergency use authorization (eua) have been administered in the united states (1). given the safety and efficacy of pfizer/biontech mrnabased vaccine and after rigorous scientific review of available data, u.s. food and drug administration (fda) has fully approved this vaccine which is now marketed under the brand name comirnaty for use in people 16 years of age or older (2). with well over 21 months into this pandemic, we still do not have any treatment that has received full fda approval for covid-19. numerous agents have been approved under eua for the treatment of sars-cov-2 infection in high-risk patients and several clinical trials are currently underway to discover the elusive drug for this purpose. the only agents currently approved for outpatient use under eua for the treatment of mild-moderate sarscov-2 infection are the three monoclonal antibody cocktails that require intravenous infusion thus limiting their utility on a widespread basis (3). an ideal drug for the treatment of covid-19 would be an oral medication that could be administered out-of-hospitals to patients with mild-moderate disease. the full genome of sarscov-2 has been identified and researchers have also used advanced microscopy techniques to map the 3d structure of the virus proteins in detail (4). together, this information has propelled the search for new drugs to treat sars-cov-2 infection that specifically target its structure and functions. in a recent non-peer reviewed article, fischer, et.al., have claimed that molnupiravir – an experimental anti-viral agent when administered orally in patients with mild to moderated sars-cov-2 infection reduced the risk of hospitalization or death by about 50% as compared to the placebo (5). these observations prompted a recent news release by merck (who developed molnupiravir in partnership with ridgeback biotherapeutics) indicating that they will be submitting an investigational new drug application to the fda seeking eua for oral treatment of patients with mild-moderate covid19 (6). molnupiravir was originally developed by drug innovations at emory university to treat influenza (7). it is a pro-drug that is metabolized into a ribonucleoside (rna) analog that resembles cytidine – a critical component of rna. molnupiravir’s anti-viral activity is exerted by a process known as lethal mutagenesis or viral error catastrophe. essentially, during replication, the viral rna incorporates molnupiravir which leads to downstream mutations resulting in catastrophic errors that adversely impact the survival of the virus. the non-peer reviewed unpublished interim data that merck is planning to use to obtain an eua emanates from interim analysis of a phase 3 trial (move-out) which was a randomized, controlled, double-blinded assessment of molnupiravir versus placebo in non-hospitalized adults with mild to moderate covid-19 with symptom onset within 5 days prior to their randomization. it is important to note that the eligible trial participants had ≥1 risk factor (such as obesity, diabetes, old age, etc.) that are associated with poor covid-19 outcomes. the primary outcome of this trial was to determine the efficacy of molnupiravir by evaluating the percentage of participants who are hospitalized and/or who have died through 29 days postrandomization. dhrp, 2021, vol. 1 (s4) 20-21 editorial http://dhrproceedings.org 21 © dhr health institute for research and development the key observations of an interim analysis of this phase 3 (move-out) study were: • molnupiravir reduced the patient’s risk of covid-19 hospitalization or death by approximately 50%: o only 28 (7.3%) patients who received molnupiravir were hospitalized, versus 53 (14.1%) patients who were administered placebo o as compared to eight (8) patients in the placebo arm, no patients who received molnupiravir died through 29 days post-randomization • molnupiravir was consistently effective against delta, gamma, and mu sars-cov2 variants • adverse events occurred in 35% and 40% of patients treated with molnupiravir versus placebo, respectively, however, trial discontinuation due to adverse event was lower (1.3%) in the treatment group as compared to the placebo group (3.4%) with the human death toll in the us due to covid19 now outstripping that during the 1918 influenza pandemic, the quest to discover an oral drug that is approved by the fda to treat patients with mildmoderate sars-cov-2 infection has achieved the revered status of the holy grail in the field of medicine and public health. interim data analysis suggests that molnupiravir has the potential to be a “drug of interest” as an oral agent to treat patients with mild-moderate covid-19. while this is indeed very encouraging, submission/review of data by the fda and other regulatory agencies along with publication of long-term follow-up of ideally a larger cohort of patients in peer-reviewed journal is quintessential to unequivocally establish the efficacy of molnupiravir in the oral treatment of non-hospitalized high-risk patients with mildmoderate sars-cov-2 infection. references 1. covid-19 dashboard. john hopkins university of medicine. 2021. https://coronavirus.jhu.edu/map.html (accessed october 02, 2021; 21:48 p.m. cst) 2. fda approves first covid-19 vaccine. 2021. https://www.fda.gov/news-events/press-announcements/fdaapproves-first-covid-19-vaccine 3. available covid-19 treatment option. 2021. https://combatcovid.hhs.gov/i-have-covid-19-now/availablecovid-19-treatment-options 4. nazario-toole ae, xia h, gibbons tf. whole-genome sequencing of sars-cov-2: using phylogeny and structural modeling to contextualize local viral evolution [published online ahead of print, 2021 feb 20]. mil med. 2021; usab031. doi:10.1093/milmed/usab031 5. fischer w, eron jj, holman w, cohen ms, fang l, szewczyk lj, sheahan tp, baric r, mollan kr, wolfe cr, duke er, azizad mm, borroto-esoda k, wohl da, loftis aj, alabanza p, lipansky f, painter wp. molnupiravir, an oral antiviral treatment for covid-19. medrxiv [preprint]. 2021 jun 17:2021.06.17.21258639. doi: 10.1101/2021.06.17.21258639. pmid: 34159342; pmcid: pmc8219109. 6. merck and ridgeback’s investigational oral antiviral molnupiravir reduced the risk of hospitalization or death by approximately 50 percent compared to placebo for patients with mild or moderate covid-19 in positive interim analysis of phase 3 study. oct 01, 2021. https://www.merck.com/news/merck-and-ridgebacksinvestigational-oral-antiviral-molnupiravir-reduced-the-risk-ofhospitalization-or-death-by-approximately-50-percentcompared-to-placebo-for-patients-with-mild-or-moderat/ 7. toots m, yoon jj, cox rm, hart m, sticher zm, makhsous n, plesker r, barrena ah, reddy pg, mitchell dg, shean rc, bluemling gr, kolykhalov aa, greninger al, natchus mg, painter gr, plemper rk. characterization of orally efficacious influenza drug with high resistance barrier in ferrets and human airway epithelia. sci transl med. 2019 oct 23;11(515): eaax5866. doi: 10.1126/scitranslmed. aax5866. pmid: 31645453; pmcid: pmc6848974 sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 manish singh, md, facs chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas disclosures: none orcid: manish singh: https://orcid.org/0000-00034146-3282 https://coronavirus.jhu.edu/map.html https://www.fda.gov/news-events/press-announcements/fda-approves-first-covid-19-vaccine https://www.fda.gov/news-events/press-announcements/fda-approves-first-covid-19-vaccine https://combatcovid.hhs.gov/i-have-covid-19-now/available-covid-19-treatment-options https://combatcovid.hhs.gov/i-have-covid-19-now/available-covid-19-treatment-options https://www.merck.com/news/merck-and-ridgebacks-investigational-oral-antiviral-molnupiravir-reduced-the-risk-of-hospitalization-or-death-by-approximately-50-percent-compared-to-placebo-for-patients-with-mild-or-moderat/ https://www.merck.com/news/merck-and-ridgebacks-investigational-oral-antiviral-molnupiravir-reduced-the-risk-of-hospitalization-or-death-by-approximately-50-percent-compared-to-placebo-for-patients-with-mild-or-moderat/ https://www.merck.com/news/merck-and-ridgebacks-investigational-oral-antiviral-molnupiravir-reduced-the-risk-of-hospitalization-or-death-by-approximately-50-percent-compared-to-placebo-for-patients-with-mild-or-moderat/ https://www.merck.com/news/merck-and-ridgebacks-investigational-oral-antiviral-molnupiravir-reduced-the-risk-of-hospitalization-or-death-by-approximately-50-percent-compared-to-placebo-for-patients-with-mild-or-moderat/ mailto:s.rao@dhr-rgv.com https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0003-4146-3282 https://orcid.org/0000-0003-4146-3282 2021, vol. 1 (s4) 17-19 https://doi.org/10.47488/dhrp.v1is4.28 http://dhrproceedings.org 17 © dhr health institute for research and development editorial insufficient scientific evidence supporting the use of ivermectin in the prevention and treatment of covid-19 ivermectin– a drug obtained following fermentation of streptomyces avermitilis, was discovered in 1975 and was approved for medical use in 1981. its discovery was hailed as an innovation in medicine resulting in the conferring of the 2015 nobel prize in physiology or medicine to william campbell and satoshi ōmura for its discovery and applications. in humans, u.s. food and drug administration (fda) has approved ivermectin for the treatment of parasite infestations which includes head lice, scabies, river blindness, lymphatic filariasis, strongyloidiasis, trichuriasis and ascariasis. in veterinary medicine, ivermectin is used to prevent and treat heartworm and acariasis, among other diseases. the anti-parasitic mode of action of ivermectin has been well-defined. it acts by binding to the gammaaminobutyric acid (gaba) receptors which results in increased influx of chloride ion with consequential hyperpolarization and paralysis. on the contrary, its mode of action in sars-cov-2 infection is debatable. while the conclusions of this manuscript are currently under reconsideration and are subject to serious scientific criticism, zaidi and dehgani-mobaraki have suggested that in addition to inhibiting host importin alpha/beta-1 nuclear transport proteins, which are part of a key intracellular transport process that viruses hijack to enhance infection by suppressing the host’s antiviral response, ivermectin also acts by inhibiting the binding of sars-cov-2 to ace-2 receptors (1). a recent study showed ivermectin had proven effective as an inhibitor of covid-19, however the experiments conducted in the study were in vitro and the trials had yet to be conducted in humans (2). despite these contradictory observations and in the face of the lack of an approved drug treatment for covid-19, many patients resorted to the use of ivermectin for both the prevention and the treatment of infection with sars-cov-2. an extremely controversial manuscript that was initially published in january 2021 and subsequently withdrawn by the editors of the frontiers in pharmacology had undesirable consequences (3). the editors concluded that this manuscript contained unsubstantiated claims and violated the journal’s editorial policies. unfortunately, despite of its withdrawal, this manuscript was used by many providers to justify the use of ivermectin for the prevention and treatment of covid-19. in an independent review of available literature, the author’s concluded that “based on the current very low‐ to low‐certainty evidence, we are uncertain about the efficacy and safety of ivermectin used to treat or prevent covid‐19. the completed studies are small, and few are considered high quality. several studies are underway that may produce clearer answers in review updates. overall, the reliable evidence available does not support the use of ivermectin for treatment or prevention of covid‐19 outside of well‐designed randomized trials” (4). regrettably, despite overwhelming scientific evidence denouncing the use of ivermectin for prevention and treatment of covid-19 supported by strong fda denunciation, the use of this drug for this indication has not abated (5). a recent study examining trends in ivermectin dispensing from outpatient retail pharmacies in the united states during the covid-19 pandemic showed an increase from an average of 3,600 prescriptions per week at the pre-pandemic baseline (march 16, 2019–march 13, 2020) to a peak of 39,000 prescriptions in the week ending on january 8, 2021. since early july 2021, outpatient ivermectin dispensing has again begun to rapidly increase, reaching more than 88,000 prescriptions in the week ending august 13, 2021. this represents a 24fold increase from the pre-pandemic baseline. (6). dhrp, 2021, vol. 1 (s4) 17-19 editorial http://dhrproceedings.org 18 © dhr health institute for research and development the recent use of ivermectin that has been formulated for veterinary use has created additional challenges. self-administering of the drug for sars-cov-2 infections have led to an unprecedented increase in calls to the texas poison center network. the texas department of state health services has issued a health advisory over the improper use of ivermectin to treat or prevent covid-19 after calls to the texas poison center network for people exposed to the drug increased 150% (7). this is a nation-wide observation as most hospitals have reported similar toxicity profiles due to iniquitous use of ivermectin for the prevention and treatment of covid-19. in addition to the fda and the u.s. centers for disease control and prevention, organizations such as american medical association and american pharmacist association have also strongly opposed the ordering, prescribing, or dispensing of ivermectin to prevent or treat covid-19 outside of a clinical trial (8). national institutes of health has designed double-blinded randomized placebocontrol clinical trials to ascertain the safety and effectiveness of ivermectin and other repurposed drugs in the prevention and treatment of covid19. dhr health institute for research and development is involved in these studies, and it is expected that the results of these prospective clinical trials would unequivocally establish the benefit (or otherwise) of these agents. considering the available scientific evidence, it is strongly recommended that ivermectin should not be prescribed and/or self-administered for the prevention or treatment of covid-19. additionally, it must be stressed that vaccination remains the most effective approach for the prevention of covid-19 and informing the public about proper treatment options is the apposite course of action towards ending this global pandemic. references 1. zaidi, a.k., dehgani-mobaraki, p. the mechanisms of action of ivermectin against sars-cov-2: an evidence-based clinical review article. j antibiot (2021). https://doi.org/10.1038/s41429-021-00430-5 2. caly, l., druce, j.d., et.al. the fda-approved drug ivermectin inhibits the replication of sars-cov-2 in vitro. antiviral res. 2020; 178:104787. 3. offord, c. frontiers pulls special covid-19 issue after content dispute. the scientist. 2021. https://www.thescientist.com/news-opinion/frontiers-pulls-special-covid-19issue-after-content-dispute-68721 4. popp, m., stegemann, m., et. al. ivermectin for preventing and treating covid-19. cochrane database of systematic reviews 2021, issue 7. art, no: cd015017. do1: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858. cd015017.pub2/full 5. why you should not use ivermectin to treat or prevent covid-19. 2021. https://www.fda.gov/consumers/consumerupdates/why-you-should-not-use-ivermectin-treat-or-preventcovid-19 6. u.s. centers for disease control & prevention. emergency preparedness and response. rapid increase in ivermectin prescriptions and reports of severe illness associated with use of products containing ivermectin to prevent or treat covid19. 2021. https://emergency.cdc.gov/han/2021/han00449.asp?acstracki ngid=uscdc_511dm64535&acstrackinglabel=han%20449%20%20general%20public&deliveryname=uscdc_511dm64535 7. texas poison center calls triple for people treating covid19 with ivermectin. 2021. https://www.msn.com/enus/health/medical/texas-poison-center-calls-triple-for-peopleself-treating-covid-19-with-ivermectin/ar-aanp5wz 8. ama, apha, ashp statement on ending use of ivermectin to treat covid-19. 2021. https://www.ama-assn.org/presscenter/press-releases/ama-apha-ashp-statement-ending-useivermectin-treat-covid-19 sohail rao, md, ma, dphil executive vice president, dhr health, 5501 s. mccoll road, edinburg, texas president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas corresponding author email: s.rao@dhr-rgv.com disclosures: none orcid: sohail rao: https://orcid.org/0000-0001-50279992 alec vasquez-kanhere dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas disclosures: none orcid: alec vasquez-kanhere: https://orcid.org/0000-0002-2566-1724 https://doi.org/10.1038/s41429-021-00430-5 https://www.the-scientist.com/news-opinion/frontiers-pulls-special-covid-19-issue-after-content-dispute-68721 https://www.the-scientist.com/news-opinion/frontiers-pulls-special-covid-19-issue-after-content-dispute-68721 https://www.the-scientist.com/news-opinion/frontiers-pulls-special-covid-19-issue-after-content-dispute-68721 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.cd015017.pub2/full https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.cd015017.pub2/full https://www.fda.gov/consumers/consumer-updates/why-you-should-not-use-ivermectin-treat-or-prevent-covid-19 https://www.fda.gov/consumers/consumer-updates/why-you-should-not-use-ivermectin-treat-or-prevent-covid-19 https://www.fda.gov/consumers/consumer-updates/why-you-should-not-use-ivermectin-treat-or-prevent-covid-19 https://emergency.cdc.gov/han/2021/han00449.asp?acstrackingid=uscdc_511-dm64535&acstrackinglabel=han%20449%20-%20general%20public&deliveryname=uscdc_511-dm64535 https://emergency.cdc.gov/han/2021/han00449.asp?acstrackingid=uscdc_511-dm64535&acstrackinglabel=han%20449%20-%20general%20public&deliveryname=uscdc_511-dm64535 https://emergency.cdc.gov/han/2021/han00449.asp?acstrackingid=uscdc_511-dm64535&acstrackinglabel=han%20449%20-%20general%20public&deliveryname=uscdc_511-dm64535 https://emergency.cdc.gov/han/2021/han00449.asp?acstrackingid=uscdc_511-dm64535&acstrackinglabel=han%20449%20-%20general%20public&deliveryname=uscdc_511-dm64535 https://emergency.cdc.gov/han/2021/han00449.asp?acstrackingid=uscdc_511-dm64535&acstrackinglabel=han%20449%20-%20general%20public&deliveryname=uscdc_511-dm64535 https://www.msn.com/en-us/health/medical/texas-poison-center-calls-triple-for-people-self-treating-covid-19-with-ivermectin/ar-aanp5wz https://www.msn.com/en-us/health/medical/texas-poison-center-calls-triple-for-people-self-treating-covid-19-with-ivermectin/ar-aanp5wz https://www.msn.com/en-us/health/medical/texas-poison-center-calls-triple-for-people-self-treating-covid-19-with-ivermectin/ar-aanp5wz https://www.ama-assn.org/press-center/press-releases/ama-apha-ashp-statement-ending-use-ivermectin-treat-covid-19 https://www.ama-assn.org/press-center/press-releases/ama-apha-ashp-statement-ending-use-ivermectin-treat-covid-19 https://www.ama-assn.org/press-center/press-releases/ama-apha-ashp-statement-ending-use-ivermectin-treat-covid-19 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0002-2566-1724 dhrp, 2021, vol. 1 (s4) 17-19 editorial http://dhrproceedings.org 19 © dhr health institute for research and development manish singh, md, facs chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas disclosures: none orcid: manish singh: https://orcid.org/0000-00034146-3282 https://orcid.org/0000-0003-4146-3282 https://orcid.org/0000-0003-4146-3282 2021, vol. 1 (2) 6-7 https://doi.org/10.47488/dhrp.v1i2.11 http://dhrproceedings.org 6 © dhr health institute for research and development trauma bulletin dhr health trauma services: providing the critical care the rio grande valley deserves jennifer (arriaga) volcy1 1 trauma program manager interim director, dhr trauma services, dhr health, edinburg, tx, usa e-mail: j.volcy@dhr-rgv.com received 03/03/2021 accepted for publication 03/04/2021 published 03/05//2021 keywords: nursing; trauma; injury; emergency; community: military the rio grande valley (rgv) lies in texas's southernmost tip, bordering mexico, with a population of 1,377,8611. it is an area of flat land with a subtropical climate and a very reasonable cost of living. i call this the hidden gem of the united states of america. having grown up in the rio grande valley (rgv), i am aware that it has been known to lack the development of other established cities across the nation. this also entails advancement in the health care industry. living in one of the most impoverished communities in the entire nation has made it difficult for valley locals to receive the proper health care they need. with the median household income being $36,0001 many people do not seek health care in this area. instead, they cross the border into mexico to treat their medical needs at an affordable price. joining the military shortly after high school and working as an aerospace medical technician allowed me to experience health care inside the u.s. military. while stationed in san antonio, tx, and working at a major military hospital, i was able to see and treat multiple patients with minor to severe injuries. one case i remember clearly was a patient involved in a severe motor vehicle accident. i happened to have attended high school with the patient's family member. knowing the individual was from the "valley," i continued to make conversation and informed them that their family was on their way to san antonio to see them. at that time, i knew they were getting the best trauma care they could receive as the military offered many physician specialties that were not available in the rgv. after completing my military tour and later becoming a registered nurse, my first job was to work in the nation's first trauma center. having the honor of working at the university of maryland r adams cowley shock trauma center was an eye-opening experience. it was a prestigious trauma center, and those living in the area were aware of its reputation. if you were involved in an accident and were flown to "shock trauma," your chances of survival were much greater. it had a state-of-the-art trauma tower with dedicated trauma resuscitation units, trauma operating rooms, specialty trauma intensive care units, step-down units, and an acute care unit. shock trauma was always ready for any injury that arrived through the door anytime – day or night. the hospital is located in the inner city of baltimore, maryland, where the crime rate is high; there were many instances where we received patients injured from gun violence. two of the most common mechanisms encountered were injuries sustained from car accidents and falls, both of which are also the leading mechanisms of injury in the rgv. motor vehicle accidents can lead to different types of injuries depending on where the blunt trauma to the body has occurred. injuries from a fall usually led to either a hip fracture for the elderly or a spinal cord injury where the patient either lost sensation or movement to a portion of their body. we treated many people with paraplegia and quadriplegics who needed special care, which increased their length of stay. traumatic brain injuries also resulted from either of those two mechanisms. traumatic brain injuries were treated in the neurointensive or intermediate unit depending on the severity of the injury. those with severe brain injuries needed close monitoring and were often intubated with monitors attached and drains draining extra fluid to relieve cranial pressure. other types of treated patients also included patients who may have sustained critical care in the rgv 2020, vol. 1 (2) 6-7 http://dhrproceedings.org 7 © dhr health institute for research and development carbon monoxide poisoning and needed to be treated using the hyperbaric chamber to allow for increased oxygen delivery. patients with existing comorbidities such as cardiovascular disease, diabetes, amongst others, made the trauma patient all the more complex to treat. why the rio grande valley? "why not," i ask myself. gaining the knowledge and experience in trauma care from the military to working in the doctor's hospital trauma services department has increased that desire to serve my community and help this region achieve what it deserves. when our patients need to be transferred north of the rgv for appropriate trauma care, most of these families cannot accompany them. many are fearful of crossing the checkpoint. in addition, they deal with a hefty medical bill for the transfer. all of this is simply because the region does not have adequate resources to care for their loved ones. i believe this is unacceptable. this hidden gem in the united states of america should not lack in trauma care to its natives. having a level 1 trauma center will increase medical resources for several professions, for example: a helicopter/prehospital team, a trauma tower with multi-trauma units, state of the art equipment, specialty rehabilitative services, injury prevention and education for the community, a trauma survivors' network to help survivors and their families cope with life post-trauma. along with trauma resources, other specialties and services will be gained. one great example relates to the covid pandemic that we are currently living in. the absolute sickest patients need to be transferred north to receive a treatment called extracorporeal membrane oxygenation (ecmo). the rgv will not be the only region to benefit from the added resources of a level 1 trauma center. mexico's northeastern region, which may include a family member or a working member of our community, will also benefit from these services. diclosures jv clinical qualifications: ms, rn, tcrn. she declares no conflicts of interest. references 1. united states census, quick facts. https://www.census.gov/quickfacts/fact/table/willacycountyt exas,starrcountytexas,cameroncountytexas,hidalgocountytex as/pst045219. accessed on 03/02/2021. https://www.census.gov/quickfacts/fact/table/willacycountytexas,starrcountytexas,cameroncountytexas,hidalgocountytexas/pst045219 https://www.census.gov/quickfacts/fact/table/willacycountytexas,starrcountytexas,cameroncountytexas,hidalgocountytexas/pst045219 https://www.census.gov/quickfacts/fact/table/willacycountytexas,starrcountytexas,cameroncountytexas,hidalgocountytexas/pst045219 special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.45 dhr proceedings ǀ http://dhrproceedings.org 1 2022, vol. 2 no. s2 1-6 commentary links between supplements and alzheimer’s disease jonathan z. aguilar1,2, derek fraire1,3, allen garza1,3, brenda martinez1,4, nataly sendejo1,4, jaime e. regalado solis1,5, stephanie suarez1,6 1 2nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2 harlingen school of health professions, harlingen, tx 3 psja southwest echs, pharr, tx 4 zapata high school, zapata, tx 5 edcouch-elsa high school, edcouch-elsa, tx 6 harlingen high school, harlingen, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 06/21/2022 accepted for publication 07/14/2022 published 07/14/2022 keywords: alzheimer’s disease; vitamins; supplements; cognition; brain introduction the brain of someone with alzheimer’s disease (ad) was first observed and identified in 1906 by german psychiatrist alois alzheimer. he arranged an autopsy of patient auguste d’s brain and found alterations that we know today as protein plaques and neurofibrillary tangles [1]. in a similar case, 5 years later, josef f. reported symptoms similar to auguste, and he was diagnosed with ad. at the time of josef’s death, alzheimer discovered that josef had protein plaque, but his brain lacked the neurofibrillary tangles that were found in auguste’s autopsy and it was disputed amongst psychiatrists whether or not this was the same disease [2]. in a study done with the autopsies of josef and auguste, it was found that auguste simply had a later stage ad than josef [2]. alzheimer was a pioneer in introducing “presenile dementia” as a new disease caused by the degeneration of the brain because of the buildup of proteins accompanied by tangles of neurons. today, we still have no known cure for ad, but there are many vitamins and dietary choices that have been rumored to prevent or even reverse ad. this commentary will review different studies and research papers done to prove or discredit the benefits of vitamins and whether or not vitamins can reverse or prevent ad. we will examine to what extent vitamins or diets can affect the outcome of someone suffering from ad and conclude whether or not supplements prove to benefit people with alzheimer’s disease. understanding the human brain the brain is the key that unlocks our consciousness, it is the doorway to understanding the essence of life, and it is the leader of our body’s nervous system. supplements and alzheimer’s aguilar, et al. https://doi.org/10.47488/dhrp.v2is2.45 dhr proceedings ǀ http://dhrproceedings.org 2 2022, vol. 2 no s2 1-6 though it may weigh less than half of a gallon of milk, the brain is an enigma, being the most complex part of the human anatomy. the most basic principle is that the brain is the command center of any sentient being. the brain contains 4 regions: the cerebrum, cerebellum, diencephalon, and brain stem [3]. each region has a crucial role in the function of our anatomy. the cerebrum itself is made of the frontal, temporal, parietal, and occipital lobes. the frontal lobe is necessary for many functions that require high amounts of cognition such as thinking, voluntary movement, speaking, and planning [3]. the parietal lobe functions to receive and process most sensory information and understand language [3]. the temporal lobe is responsible for hearing, object recognition, and the formation of visual memories [3]. the occipital lobe focuses mainly on vision, aiding in determining color, distance, and visual perception [3]. the cerebellum mainly controls coordination, balance, and maintenance of posture [4]. the diencephalon, the often-forgotten portion of the brain due to its medial location, helps process and relay sensory information, and it aids with autonomic control [5]. the brain stem is responsible for breathing, temperature, and heart rate [4]. figure 1 the brain executes these functions by dispatching messages across the body via its central and peripheral nervous systems. the central nervous system contains the brain and spinal cord whereas the peripheral nervous system consists of the autonomic and somatic nervous systems. the somatic nervous system controls voluntary actions. on the other hand, the autonomic nervous system is in charge of involuntary functions [6]. while the brain may consist of many different regions and sub regions, all of these parts work together efficiently and effectively to carry out the body’s functions. any disruptions to this fragile system can cause harmful effects. ad is an extraordinary example of the previous statement. pathophysiology of alzheimer’s alzheimer’s disease is a growing problem in american society. about 5 million americans see the effects of ad, this estimate will likely triple to 14 million, by the year 2060 [7]. ad is a dynamic, gradual progressive mental deterioration that commonly occurs in old age, and it is the leading cause of dementia [8]. it is caused by the buildup of protein that degenerates neurons in the entorhinal cortex and hippocampus, which is the connection to the memory part of the brain. it will then affect the cerebral cortex which is responsible for much of our language, reasoning, and social behavior. β-amyloid and tau are the proteins that do the degeneration. amyloid builds up and creates plaque around and between the cells, which will disrupt cell function. tau is the protein that assists in the generation of microtubules. these microtubules are essential in transporting nutrients, and the excess tau will begin to tangle and restricts nutrients from being transported [8]. figure 2 these slight changes in the nervous system are enough to cause many problems, proving just how fragile our nervous system is. although it may not be a sure fix, staying informed of the risk factors and the accrual of a sufficient number of beneficial vitamins supplements and alzheimer’s aguilar, et al. https://doi.org/10.47488/dhrp.v2is2.45 dhr proceedings ǀ http://dhrproceedings.org 3 2022, vol. 2 no s2 1-6 may assist in the prevention of ad. the possible risk factors include genetics, head injuries, vascular disease, infections, environmental factors, and lifestyle [8]. in theory, if plaque can be prevented from forming and the tau from tangling, there will be an effective prevention of ad by addressing the problem at its root. how vitamins affect neurodegeneration it is believed that the degeneration of the brain can be prevented with vitamins that include beneficial supplements to the brain. the common over-the-counter vitamins bought include omega-3, vitamin d, b12, and folic acid, which are widely disputed to reduce the probability of dementia and reduce cognitive decline in the early stage of ad [9]. based on the available data, it is believed that deficiencies in vitamins may affect the brain and increase your risk of having ad [10]. for example, having a deficiency in vitamin d has shown to increase your chances of developing ad, and low levels of vitamin b are associated with high levels of amyloid in the brain [10,11]. it has been proposed that many other vitamins can have a great effect on one's health particularly when it comes to ad. specific vitamins and their effects on the treatment of alzheimer’s disease omega 3 fatty acids since a low level of dha, a type of omega 3 fatty acid, in the hippocampus and frontal cortex is usually detected in ad patients, a diet that includes a higher intake of omega 3 with dha can improve the symptoms of ad [12]. although there hasn’t been concrete evidence that omega 3 can effectively eradicate alzheimer’s, when taken long before symptoms arise, can be used as prevention and even help ease symptoms when they are mild [12]. foods rich with omega 3 include salad dressing, nuts, fish, tomatoes, poultry, cruciferous vegetables, fruits, dark and green leafy vegetables [13]. axona (caprylic acid) axona, also known as caprylidene, is a medical food and supplement that has caprylic acid as its active ingredient. it is a medium-chain triglyceride that serves as an energy source for brain cells that have lost their ability to produce glucose. in the case of an ad patient, it can replace the role of glucose. although it hasn’t been approved by the fda and is not recommended by the alzheimer's association, it has been observed through a small study that there was a slight improvement in cognitive function and memory in patients with moderate and mild forms of ad [14]. vitamin d vitamin d is a nutrient humans need that comes mainly from sun exposure, over-the-counter supplements, and foods rich in this mineral (cod liver oil, salmon, tuna fish, orange juice fortified, sardines, beef liver). a meta-analysis conducted by a group of researchers at neurology concluded that patients with ad had a lower presence of vitamin d than the control group of seemingly healthy individuals [15]. results from a similar meta-analysis suggested that subjects deficient in vitamin d produced an increased risk of developing ad by 21% more than those with higher levels of the supplement [16]. although it is observational, these studies pave the way for future trials that further prove whether vitamin d can successfully delay and prevent the onset of ad/dementia in geriatric individuals [17]. figure 3 vitamin b12 and vitamin b9 vitamin b9, also known as folate or folic acid, is a supplement that aids in the development of the central nervous system. although it is highly regarded as a symptom reliever for ad patients, there is insufficient evidence that the combination of vitamins supplements and alzheimer’s aguilar, et al. https://doi.org/10.47488/dhrp.v2is2.45 dhr proceedings ǀ http://dhrproceedings.org 4 2022, vol. 2 no s2 1-6 b9 and b12 or either one alone can combat cognitive decline as no adverse or beneficial effects were concluded since patients did not experience a change [18, 19]. the mediterranean diet, a diet that combats alzheimer’s while buying vitamins at your local supermarket is easily accessible, there are diets constructed carefully to improve mental and physical health. for example, in greece, the mediterranean diet is based on fish, olive oil, nuts, and the careful consumption of wine [20]. this diet supplies the consumer with monosaturated fats, omega-3s, and antioxidants [21]. not only does a mediterranean diet give our brain dha [22] and antioxidants that protect neurons from oxidant stress damage [23], but its containment of monosaturated fats can also decrease your risk of cardiovascular disease [24]. although buying vitamins over the counter may be beneficial, there are plenty of dietary options that provide the nutrients and vitamins our brain needs to avoid, prevent, or stall out the effects of ad and neurodegeneration. conclusion alzheimer’s disease is a serious problem facing the united states today. it is important to know what may help prevent or ease the effects of alzheimer’s disease. it is also important to know the effects, if any, of the different supplements discussed. we can conclude that folate and b12 with folic acid do not have any link to ad. although in the cases of omega 3s and vitamin d, it is shown that low levels of each are detected in ad patients. while these supplements may not be cures or foolproof prevention for alzheimer’s, the fact that low levels of each are prevalent in patients with ad is enough to suggest a sufficient amount of each is in your body at any given time. axona has been shown to express slight improvement in cognitive function and memory in patients with a moderate and mild form of ad. an alternative route of reaping the benefits of these supplements is modifying your dietary plan. if you use your diet to your advantage, you are able to consume beneficial vitamins and minerals that have been proven to slow the progression of ad. clinical research still needs to be conducted to investigate additional supplements and to discover any other variables that may affect the development of ad. clinical research should not be something to fear because its main goal is to benefit society. the stigma around clinical research should be broken down to normalize clinical research. this will cause people to willingly participate, and this will help increase our knowledge of the world around us. it is also important to take action in your community by speaking on alzheimer’s disease and educating yourself and others about clinical research, including why it’s safe and beneficial. together, we can work to find out more about alzheimer’s disease and work toward a cure. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected and region one esc paths references 1. weller, j., & budson, a. (2018). current understanding of alzheimer's disease diagnosis and treatment. f1000research, 7, f1000 faculty rev-1161. https://doi.org/10.12688/f1000research.1450 6.1 2. hippius, h., & neundörfer, g. (2003). the discovery of alzheimer's disease. dialogues in clinical neuroscience, 5(1), 101–108. https://doi.org/10.31887/dcns.2003.5.1/hhi ppius 3. anatomy of the brain mayfield brain and spine. retrieved on june 14, 2022 from https://mayfieldclinic.com/pe-anatbrain.htm https://doi.org/10.12688/f1000research.14506.1 https://doi.org/10.12688/f1000research.14506.1 https://doi.org/10.31887/dcns.2003.5.1/hhippius https://doi.org/10.31887/dcns.2003.5.1/hhippius https://mayfieldclinic.com/pe-anatbrain.htm supplements and alzheimer’s aguilar, et al. https://doi.org/10.47488/dhrp.v2is2.45 dhr proceedings ǀ http://dhrproceedings.org 5 2022, vol. 2 no s2 1-6 4. brain anatomy and how the brain works. johns hopkins medicine. (2021, july 14). retrieved june 14, 2022, from https://www.hopkinsmedicine.org/health/co nditions-and-diseases/anatomy-of-thebrain?amp=true 5. libretexts. (2020, august 14). 11.6a: functions of the diencephalon. medicine libretexts. retrieved june 14, 2022, from https://med.libretexts.org/bookshelves/anat omy_and_physiology/book%3a_anatomy_ and_physiology_(boundless)/11%3a_centr al_nervous_system/11.6%3athe_diencep halon/11.6a%3a_functions_of_the_dience phalon 6. guy-evans, o. (2021, april 23). peripheral nervous system. peripheral nervous system (pns) parts and function | simply psychology. retrieved june 16, 2022, from https://www.simplypsychology.org/peripher al-nervous-system.html 7. centers for disease control and prevention. (2019, august 20). the truth about aging and dementia. centers for disease control and prevention. retrieved june 14, 2022, from https://www.cdc.gov/aging/publications/feat ures/alz-greater-risk.html 8. breijyeh, z., & karaman, r. (2020). comprehensive review on alzheimer's disease: causes and treatment. molecules (basel, switzerland), 25(24), 5789. https://doi.org/10.3390/molecules25245789 9. grimm, m., michaelson, d. m., & hartmann, t. (2017). omega-3 fatty acids, lipids, and apoe lipidation in alzheimer's disease: a rationale for multi-nutrient dementia prevention. journal of lipid research, 58(11), 2083–2101. https://doi.org/10.1194/jlr.r076331 10. berridge m. j. (2017). vitamin d deficiency accelerates ageing and age-related diseases: a novel hypothesis. the journal of physiology, 595(22), 6825–6836. https://doi.org/10.1113/jp274887 11. aisen, p. s., schneider, l. s., sano, m., diazarrastia, r., van dyck, c. h., weiner, m. f., bottiglieri, t., jin, s., stokes, k. t., thomas, r. g., thal, l. j., & alzheimer disease cooperative study (2008). high-dose b vitamin supplementation and cognitive decline in alzheimer disease: a randomized controlled trial. jama, 300(15), 1774–1783. https://doi.org/10.1001/jama.300.15.1774 12. shabir, osman. (2019, january 15). omega3 and alzheimer’s disease. news-medical. retrieved on june 14, 2022 from https://www.newsmedical.net/health/omega-3-andalzheimers-disease.aspx. 13. danielle swanson, robert block, shaker a. mousa, omega-3 fatty acids epa and dha: health benefits throughout life, advances in nutrition, volume 3, issue 1, january 2012, pages 1–7, https://doi.org/10.3945/an.111.000893 14. jonathan graff-radford, m.d (april 20,2019) axona: medical food to treat alzheimer’s mayo clinic https://www.mayoclinic.org/diseasesconditions/alzheimers-disease/expertanswers/axona/faq-20057790 15. bailon, c., griffith, l. e., strifler, l., henderson, m., patterson, c., heckman, g., llewellyn, d. j., & raina, p. (2012). vitamin d, cognition, and dementia: a systematic review and meta-analysis. neurology, 79(13), 1397–1405. https://doi.org/10.1212/wnl.0b013e31826c 197f 16. shen, l., & ji, h. f. (2015). vitamin d deficiency is associated with increased risk of alzheimer's disease and dementia: evidence from meta-analysis. nutrition journal, 14, 76. https://doi.org/10.1186/s12937-015-0063-7 17. littlejohns, t. j., henley, w. e., lang, i. a., annweiler, c., beauchet, o., chaves, p. h., fried, l., kestenbaum, b. r., kuller, l. h., langa, k. m., lopez, o. l., kos, k., soni, m., & llewellyn, d. j. (2014). vitamin d and the risk of dementia and alzheimer disease. neurology, 83(10), 920–928. https://doi.org/10.1212/wnl.000000000000 0755 18. malouf, m., grimley, e. j., & areosa, s. a. (2003). folic acid with or without vitamin b12 for cognition and dementia. the cochrane database of systematic reviews, (4), cd004514. https://doi.org/10.1002/14651858.cd00451 4 https://www.hopkinsmedicine.org/health/conditions-and-diseases/anatomy-of-the-brain?amp=true https://www.hopkinsmedicine.org/health/conditions-and-diseases/anatomy-of-the-brain?amp=true https://www.hopkinsmedicine.org/health/conditions-and-diseases/anatomy-of-the-brain?amp=true https://med.libretexts.org/bookshelves/anatomy_and_physiology/book%3a_anatomy_and_physiology_(boundless)/11%3a_central_nervous_system/11.6%3athe_diencephalon/11.6a%3a_functions_of_the_diencephalon https://med.libretexts.org/bookshelves/anatomy_and_physiology/book%3a_anatomy_and_physiology_(boundless)/11%3a_central_nervous_system/11.6%3athe_diencephalon/11.6a%3a_functions_of_the_diencephalon https://med.libretexts.org/bookshelves/anatomy_and_physiology/book%3a_anatomy_and_physiology_(boundless)/11%3a_central_nervous_system/11.6%3athe_diencephalon/11.6a%3a_functions_of_the_diencephalon https://med.libretexts.org/bookshelves/anatomy_and_physiology/book%3a_anatomy_and_physiology_(boundless)/11%3a_central_nervous_system/11.6%3athe_diencephalon/11.6a%3a_functions_of_the_diencephalon https://med.libretexts.org/bookshelves/anatomy_and_physiology/book%3a_anatomy_and_physiology_(boundless)/11%3a_central_nervous_system/11.6%3athe_diencephalon/11.6a%3a_functions_of_the_diencephalon https://med.libretexts.org/bookshelves/anatomy_and_physiology/book%3a_anatomy_and_physiology_(boundless)/11%3a_central_nervous_system/11.6%3athe_diencephalon/11.6a%3a_functions_of_the_diencephalon https://www.simplypsychology.org/peripheral-nervous-system.html https://www.simplypsychology.org/peripheral-nervous-system.html https://www.cdc.gov/aging/publications/features/alz-greater-risk.html https://www.cdc.gov/aging/publications/features/alz-greater-risk.html https://doi.org/10.3390/molecules25245789 https://doi.org/10.1194/jlr.r076331 https://doi.org/10.1113/jp274887 https://doi.org/10.1001/jama.300.15.1774 https://www.news-medical.net/health/omega-3-and-alzheimers-disease.aspx https://www.news-medical.net/health/omega-3-and-alzheimers-disease.aspx https://www.news-medical.net/health/omega-3-and-alzheimers-disease.aspx https://doi.org/10.3945/an.111.000893 https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/axona/faq-20057790 https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/axona/faq-20057790 https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/axona/faq-20057790 https://doi.org/10.1212/wnl.0b013e31826c197f https://doi.org/10.1212/wnl.0b013e31826c197f https://doi.org/10.1186/s12937-015-0063-7 https://doi.org/10.1212/wnl.0000000000000755 https://doi.org/10.1212/wnl.0000000000000755 https://doi.org/10.1002/14651858.cd004514 https://doi.org/10.1002/14651858.cd004514 supplements and alzheimer’s aguilar, et al. https://doi.org/10.47488/dhrp.v2is2.45 dhr proceedings ǀ http://dhrproceedings.org 6 2022, vol. 2 no s2 1-6 19. malouf, r., & areosa sastre, a. (2003). vitamin b12 for cognition. the cochrane database of systematic reviews, (3), cd004326. https://doi.org/10.1002/14651858.cd00432 6 20. davis, c., bryan, j., hodgson, j., & murphy, k. (2015). definition of the mediterranean diet; a literature review. nutrients, 7(11), 9139–9153. https://doi.org/10.3390/nu7115459 21. tosti, v., bertozzi, b., & fontana, l. (2018). health benefits of the mediterranean diet: metabolic and molecular mechanisms. the journals of gerontology. series a, biological sciences and medical sciences, 73(3), 318– 326. https://doi.org/10.1093/gerona/glx227 22. healy-stoffel, m., & levant, b. (2018). n-3 (omega-3) fatty acids: effects on brain dopamine systems and potential role in the etiology and treatment of neuropsychiatric disorders. cns & neurological disorders drug targets, 17(3), 216–232. https://doi.org/10.2174/18715273176661804 12153612 23. pandya, c. d., howell, k. r., & pillai, a. (2013). antioxidants as potential therapeutics for neuropsychiatric disorders. progress in neuro-psychopharmacology & biological psychiatry, 46, 214–223. https://doi.org/10.1016/j.pnpbp.2012.10.017 24. teresa scanlan, c. n. p. (2021, june 21). mediterranean diet for your heart. mayo clinic health system. retrieved june 15, 2022, from https://www.mayoclinichealthsystem.org/ho metown-health/speaking-of-health/eatingfor-your-heart-the-mediterranean-diet 25. [fig. 1] brain lobes with its functions [3]. researchgate. (n.d.). retrieved june 15, 2022, from https://www.researchgate.net/figure/brainlobes-with-its-functions-3_fig2_340865332 26. [fig. 2] breijyeh, z., & karaman, r. (2020). comprehensive review on alzheimer's disease: causes and treatment. molecules (basel, switzerland), 25(24), 5789. https://doi.org/10.3390/molecules25245789 27. [fig. 3] mentella, m. c., scaldaferri, f., ricci, c., gasbarrini, a., & miggiano, g. (2019). cancer and mediterranean diet: a review. nutrients, 11(9), 2059. https://doi.org/10.3390/nu11092059 https://doi.org/10.1002/14651858.cd004326 https://doi.org/10.1002/14651858.cd004326 https://doi.org/10.3390/nu7115459 https://doi.org/10.1093/gerona/glx227 https://doi.org/10.2174/1871527317666180412153612 https://doi.org/10.2174/1871527317666180412153612 https://doi.org/10.1016/j.pnpbp.2012.10.017 https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/eating-for-your-heart-the-mediterranean-diet https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/eating-for-your-heart-the-mediterranean-diet https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/eating-for-your-heart-the-mediterranean-diet https://www.researchgate.net/figure/brain-lobes-with-its-functions-3_fig2_340865332 https://www.researchgate.net/figure/brain-lobes-with-its-functions-3_fig2_340865332 https://doi.org/10.3390/molecules25245789 https://doi.org/10.3390/nu11092059 volume 2 no. s3: second quarter editorial https://doi.org/10.47488/dhrp.v2is3.68 dhr proceedings ǀ http://dhrproceedings.org 10 2022, vol. 2 no. s3 10-15 editorial the rising incidence of sars-cov-2 infection in the greater rio grande valley: is the covid-19 pandemic over? sohail rao, md, ma, dphil,1 and manish singh, md, facs, fasmbs2 1executive vice president for research & leadership development, dhr health, 5501 s. mccoll road, edinburg, texas 78539, and founding president & chief executive officer, dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. orcid: https://orcid.org/0000-0001-5027-9992 2dhr health bariatric and metabolic institute and chief executive officer, dhr health, 5501 s. mccoll road, edinburg, texas 78539 and dhr health bariatric & metabolic institute, 5500 raphael drive, edinburg, tx 79539 orcid: https://orcid.org/0000-0003-4146-3282 correspondence should be addressed to: sohail rao, md, ma, dphil., dhr health institute for research & development, 5323 s. mccoll road, edinburg, texas 78539. e-mail: s.rao@dhr-rgv.com. keywords: covid-19; sars-cov-2; ba.4; ba.5; omicron; cdc: centers for disease control and prevention; fda: u.s. food and drug administration; who: world health organization the first case of sars-cov-2 infection was reported in 2019 by the world health organization for a patient in wuhan, china (1). in the united states, the first case was reported in january 2020 of a patient who had travelled from wuhan china to snohomish county, washington (2). in the hidalgo county, rio grande valley, texas the first confirmed patient with covid-19 was treated on march 21, 2020. globally since the identification of the first case in wuhan china and as of july 28, 2022, over 574 million (approximately 7.2% of the world population) people have been diagnosed with covid-19 and over 6.3 million people have died because of sars-cov-2 infection (table 1). during the same period, over 91 million (approximately 27% of the population) people in united states were diagnosed as covod-19 positive and over one (1) million people have died (table 1). in texas with a population of over 29 million people, over 7.5 million (approximately 26% of the population) residents acquired sars-cov-2 infection and over 300,000 have died due to covid19 (table 1). the greater rio grande valley (g-rgv) in south texas is comprised of eight counties (hidalgo, cameron, webb, starr, willacy, zapata, jim hogg, and brooks) and according to the 2020 united states census, it has a total population of over 1.6 million people (3). it is one of the most rapidly growing regions in the united states and enjoys the uniqueness of having over 90% of the population who are of hispanic ethnicity (3). since the identification of the first case of sars-cov-2 infection in march 2020 (table 2), over 488,000 (approximately 29% of the https://orcid.org/0000-0001-5027-9992 https://orcid.org/0000-0003-4146-3282 mailto:s.rao@dhr-rgv.com rao, et al rising incidence of sars-cov-2 infection https://doi.org/10.47488/dhrp.v2is3.68 dhr proceedings ǀ http://dhrproceedings.org 11 2022, vol. 2 no. s3 10-15 population) people in the g-rgv have been diagnosed positive with covid-19 and over 7,600 people have died as a consequence of this infection (table 2; 4). the advent of covid-19 mrna vaccines in december 2020 positively impacted the outcome of sars-cov-2 infection both globally as well as in the united states (5, 6). as of july 27, 2022, over 229 million (approximately 67.2% of the population) people in the united states have been fully vaccinated, whereas during the same period over 50 million (approximately 91.8% of the population) people over the age of 65 years have been fully vaccinated (figure 1). as of july 28, 2022, in texas, over 17.8 million people have been fully vaccinated and over 7 million people have received at least one booster. unfortunately, in the united states, only approximately 48% (over 107 million) people who qualify have received the first booster and only over 19 million (approximately 30.9%) people >50 years and over 13 million (approximately 37.8%) people >65 years who qualify have received the second booster (7). these observations are alarming considering the results of a recent study that was published in the journal science which suggested that covid-19 vaccine boosters provided adequate protection against omicron sub-lineages (8). this gradual decline in compliance with cdc recommendations for receiving primary and booster vaccinations and the concomitant lackadaisical approach to maintaining appropriate safety precautions are converging factors that are leading to an observed increase in infection from omicron ba.4 and ba.5 sub-lineages. as depicted in table 1 and 2, in the last 28 days, there is a marked increase in both the frequency of infection as well death from covid-19. in the last 28 days, in united states, over 27 million people have been infected with sars-cov-2 virus and during the same period over 55,000 people have died (table 1). in texas during the same period, over 300,000 people have been diagnosed as covid-19 positive and 385 people have died (table 1). additionally, in the last 28 days in the g-rgv, over 22,000 people have been diagnosed with sars-cov-2 infection and 34 people have died because of covid-19 (table 2). it is noteworthy that positive home tests are not reported to the central registry thus it is highly likely that these numbers are not reflective of the actual incidence of sars-cov-2 infection in the community. from the evidence presented above, we conclude that the covid-19 is still a pandemic and has the potential to cause more fatality if adequate measures are not taken promptly. we recommend that people seriously consider getting vaccinated and observe safety precautions to abate the incidence of sars-cov-2 infection, reduce the frequency of mutations, and minimize the attendant lethality. funding: the project was funded by a seed grant from the dhr health institute for research & development and the dhr health conflict of interest: the authors have reported no conflict of interest rao, et al rising incidence of sars-cov-2 infection https://doi.org/10.47488/dhrp.v2is3.68 dhr proceedings ǀ http://dhrproceedings.org 12 2022, vol. 2 no. s3 10-15 references 1. covid-19 – china. world health organization. january 5, 2020. https://www.who.int/emergencies/diseaseoutbreak-news/item/2020-don229 2. holshue ml, debolt c, lindquist s, lofy kh, wiesman j, bruce h, spitters c, ericson k, wilkerson s, tural a, diaz g, cohn a, fox l, patel a, gerber si, kim l, tong s, lu x, lindstrom s, pallansch ma, weldon wc, biggs hm, uyeki tm, pillai sk; washington state 2019-ncov case investigation team. first case of 2019 novel coronavirus in the united states. n engl j med. 2020 mar 5;382(10):929-936. doi: 10.1056/nejmoa2001191. epub 2020 jan 31. pmid: 32004427; pmcid: pmc7092802. 3. our changing population – texas. usa facts. https://usafacts.org/data/topics/peoplesociety/population-and-demographics/ourchangingpopulation/state/texas?utm_source=google& utm_medium=cpc&utm_campaign=&msclk id=17d027689f6f128bad6d458fa7f6ef24 4. johns hopkins university & medicine. covid-19 resource center. https://coronavirus.jhu.edu/map.html 5. thanh le t, andreadakis z, kumar a, et. al. the covid-19 vaccine landscape. may 2020. nature reviews. drug discovery. 19 (5): 305-306. doi: https://doi.org/10.1038/d41573-020-00073-5 6. le tt, cramer jp, chen r, mayhew s (october 2020). "evolution of the covid-19 vaccine development landscape". nature reviews. drug discovery. 19 (10): 667–668. doi:10.1038/d41573-020-00151-8. pmid 32887942. s2cid 221503034 7. covid-19 vaccination data – united states. cdc. https://covid.cdc.gov/coviddata-tracker/#vaccinations_vacc-peopleadditional-dose-totalpop (data accessed as of july 27, 2022 @ 06;00 hrs est). 8. bowen je, addetia a, dang hv, et.al. omicron spike function and neutralizing activity elicited by a comprehensive panel of vaccines. science. 2022 jul 19:eabq0203. doi: 10.1126/science.abq0203. epub ahead of print. pmid: 35857529. rao, et al rising incidence of sars-cov-2 infection https://doi.org/10.47488/dhrp.v2is3.68 dhr proceedings ǀ http://dhrproceedings.org 13 2022, vol. 2 no. s3 10-15 table 1: number of covid-19 positive cases and deaths as of the start of the pandemic and in the last 28 days* *as of july 28, 2022 @ 16:00 hours rao, et al rising incidence of sars-cov-2 infection https://doi.org/10.47488/dhrp.v2is3.68 dhr proceedings ǀ http://dhrproceedings.org 14 2022, vol. 2 no. s3 10-15 table 2: number of covid-19 positive cases and deaths in the greater rio grande valley, south texas as of the start of the pandemic and in the last 28 days* *as of july 28, 2022 @ 16:00 hours rao, et al rising incidence of sars-cov-2 infection https://doi.org/10.47488/dhrp.v2is3.68 dhr proceedings ǀ http://dhrproceedings.org 15 2022, vol. 2 no. s3 10-15 figure 1: covid-19 vaccination in the united states* (adopted from: https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-additional-dosetotalpop) *as of july 27, 2022 @ 06:00 hours est **fully vaccinated: having received two doses of primary vaccination of mrna vaccine https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-additional-dose-totalpop https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-additional-dose-totalpop special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.46 dhr proceedings ǀ http://dhrproceedings.org 7 2022, vol. 2 no. s2 7-10 commentary youth minorities struggle with covid-19 emma tejeda1,2, dulce garcia1,3, katelynn ferreira1,4, keyla trejo1,5, nevan nieto1,6, evelina ruiz1,7, ana sanchez1,8, cytlali martinez1,9, destiny esquivel1,10 1 2nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2 nikki rowe high school, mcallen tx 3 psja southwest early college high school, pharr tx 4 university of texas rio grande valley, mathematics and science academy, mcallen tx 5 edcouch-elsa high school, edcouch tx 6 harlingen high school south, harlingen tx 7 port isabel high school, port isabel tx 8 medical professions, olmito tx 9 psja southwest, pharr tx 10 san benito high school, san benito tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 06/21/2022 accepted for publication 07/13/2022 published 07/14/2022 keywords: covid-19; minorities; youth; asians; hispanics; introduction as the world continues to battle covid-19 as one, many young americans have found themselves fighting a battle all alone (1). some argued that government imposed lockdown and changes in routines may have worsened depression, and anxiety in youth minorities while others suggested mental health symptoms seemed to be reduced possibly due to the feeling of safety that being at home provided, the amount of time spent with family, and lessened academic pressure (1). however, as the lockdown went on for months, researchers confirmed that covid-19 negatively affected and further isolated young minorities who were already suffering with mental health disorders (2). evidence highlights how american youth, particularly youth minorities, facing socio-economic challenges and cultural factors had their mental health severely impacted (3). in many cases, this revealed the lack of communication, information and resources available to them (4). as a result, minority adolescents have become further disadvantaged and unable to perform crucial life skills due to depression, anxiety and the lack of interaction. background covid-19 is an infectious disease caused by sars-cov-2. this novel virus produces a respiratory disease in humans that may lead to severe disease and progression to hospitalization and even death. the first case was found in december 2019. covid-19 greatly impacted millions across the globe but vaccinations against sars-cov-2 greatly reduced the risk of severe infections (5). although disease severity has been reduced, the social impact of covid-19 has led to suffering with depression and anxiety in many tejeda, et al. youth struggles’ with covid-19 https://doi.org/10.47488/dhrp.v2is2.46 dhr proceedings ǀ http://dhrproceedings.org 8 2022, vol. 2 no. s2 7-10 individuals and has exacerbated it in those already impacted. many studies show that covid-19 impacted the mental health of adolescents (6). anxiety and depression are more than just feelings; they are disorders that interfere with everyday activities. the national institute of mental health says major depressive disorder or clinical depression is a common but serious mood disorder. it causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. to be diagnosed with depression, the symptoms must be present for at least two weeks (7). covid-19 has also led to the increase in anxiety disorders. occasional anxiety is a normal part of life. many people worry about things such as health, money, or family problems. but anxiety disorders involve more than temporary worry or fear. for people with an anxiety disorder, the anxiety does not go away and can get worse over time (6). covid contributed to the decline in teens’ mental health, especially in youth minorities. youth minorities struggled an abundant amount during government lockdowns and continue to struggle even today. causes covid-19 had a significantly negative effect on the mental health of many racial minority teens. factors such as financial hardships, domestic abuse, marital status, lack of social interaction, racism, etc., greatly changed the way this youth group spent their time while in quarantine. these factors caused these teens to feel an extreme amount of stress, which in many circumstances led to many negative mental effects. when talking about monetary issues, domestic abuse, and marital status, all these issues connect to economic impacts caused by covid-19. a great number of parents of minority teens lost their jobs due to covid-19, or they weren’t able to work because of fear of contracting the virus. the lack of money in households led to many parental fights which increased the rate of domestic abuse (2). however, the economic decline wasn’t the only thing that led to these issues. the struggle with mental health was also greatly influenced by racism. many of these teens were faced with discrimination from people targeting their race. there were many hate crimes targeted towards minority groups during the pandemic, which led to fear in these teens when going out into society. many feared leaving their house and for others lockdown restrictions restrained them from doing so. this led to lack of social interaction which caused a decrease in communication skills (8). latino youth--cultural and social effects covid-19 affected cultural norms in many ways, particularly for the hispanic community. for instance, a popular coming of age event is the celebration of young women with a quinceanera. this is a wedding-like event that honors young girls and their contributions to society. quinceaneras are way more than just parties; they play a vital role in a young woman's confidence to take on the challenges that life will bring. not being able to participate in an event that has taken place for generations before can take a huge toll on young latina women. the 15-year anticipation and planning for this tradition that is now futile for some families can really affect the mental health of these young individuals. the hispanic culture traditionally embraces the “pull yourself up by your bootstraps” mentally. it may be difficult for some youth and adolescents to subscribe to this way of thinking. when a minority hispanic teenager complains or says that they are struggling with depression, the parents usually don't believe them and don't believe such disorder exists. parents invalidate, making them alienate themselves and therefore dig the proverbial hole for their own kids even deeper. covid-19 has only worsened this dilemma during the pandemic and after. the mental health of youth minorities is so important and more awareness can help youth develop coping mechanisms. as an added burden, latino children that come from immigrant families are at a heightened risk of mental health issues like depression due to the increased amount of media coverage on the deportation of children like themselves or family members. on social media, there is a mass amount of viral videos and information about the immigrant latino community placed at the border during the pandemic. these videos included imagery of families being separated, sleeping in foil bags, and being deprived of their basic needs. the close proximity of everyone in these videos made it a covid-19 hotspot. these videos were shown to increase depression symptoms in latino children (11). for many, this could turn into a reality as many are undocumented and don’t have stable ground. tejeda, et al. youth struggles’ with covid-19 https://doi.org/10.47488/dhrp.v2is2.46 dhr proceedings ǀ http://dhrproceedings.org 9 2022, vol. 2 no. s2 7-10 asian youth the mental health effects of covid-19 affected hispanic youth was also prevalent among american asian youth. there was an increase in anxiety and depression within the asian community that resulted from the fear of being racially profiled and hate crime. hate crimes against the asian population increased 145% in the 16 major cities in the us from 2019 to 2020. a study showed that 543 chinese american families have faced either direct or indirect racism either in person or online (12). this shows how common it was to be racially profiled, and validates their heightened feelings of anxiety and depression. there was a decrease in job availability regarding the asian-owned businesses that required close contact such as beauty services. the unemployment rate for asian americans fell the lowest compared to other ethnicities during the covid19 pandemic (12). this could also be another factor affecting the youth because financial hardships caused an even greater effect on their social and emotional health. management covid-19 has brought great stress among the people of the united states and as we slowly start returning to our everyday life we see that a lot of people are left with mental health issues due to the lockdown. just like every other disease or illness, mental health should also be treated as soon as possible. when it comes to minorities such as asians, hispanics, and african americans, it can be difficult to access these treatments. however, out of all the minorities listed previously, hispanics have the lowest rates of medical insurance in the united states, which shows just how hard it is for hispanics to access healthcare (13). this not only makes it nearly impossible for these groups to get mental health but also exacerbates the spread of sars-cov-2 as many of them don't get the opportunity to get tested or go to the doctor. something that can be done to prevent the spread of covid-19 in a community is by making covid testing and care accessible and equal for everyone. other things that can be done to manage stress is to communicate with other people such as neighbors, classmates, counselors and healthcare professionals at schools so that they are able to create a feeling of security and would furthermore help lower the risk of depression (14). aftermath the covid-19 pandemic has left a significant impact on the youth minorities and how they are struggling in everyday life. from social to domestic abuse, racism to financial hardship, and marital status to stress. all this forever alters the way the youth is living their lives and how they should be taking care of themselves. some struggle on where to look for healthcare being available, and even reaching out to those in fear of being assaulted or racially profiled. they are expected to get straight back to how they were living before, which contributes to even more stress. all these public problems have a domino effect on each other leaving our youth scared and their mental health affected. this is not a gradual problem, but rather an emergency call for the future of the development and safety of children. due to the prolonged lockdowns of the u.s. there are many neurological developments being impaired in young generations (14). not only is it affecting their development, it is also affecting their economic status that may lead to some falling into poverty, again exacerbating their health and social challenges. children are trying to catch up to the world's expectations despite extreme isolation that covid 19 induced, leaving youth to hastily gain critical life skills and hopefully make a healthy transition into adulthood. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected and region one esc paths references 1. covid-19 conversations: a deeper dive into the impact of covid-19 on minority youth. (n.d.). www.uh.edu. retrieved june 14, 2022, from https://uh.edu/newstejeda, et al. youth struggles’ with covid-19 https://doi.org/10.47488/dhrp.v2is2.46 dhr proceedings ǀ http://dhrproceedings.org 10 2022, vol. 2 no. s2 7-10 events/stories/2021/october-2021/10132021covid-impact-minority-youth-sharp.php 2. singh s, roy d, sinha k, parveen s, sharma g, joshi g. impact of covid-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. psychiatry res. 2020 nov;293:113429. doi: 10.1016/j.psychres.2020.113429. 3. penner f, hernandez ortiz j, sharp c. change in youth mental health during the covid-19 pandemic in a majority hispanic/latinx us sample. j am acad child adolesc psychiatry. 2021 apr;60(4):513-523. doi: 10.1016/j.jaac.2020.12.027. 4. cortés-garcía l, hernández ortiz j, asim n, sales m, villareal r, penner f, sharp c. covid-19 conversations: a qualitative study of majority hispanic/latinx youth experiences during early stages of the pandemic. child youth care forum. 2021 sep 28:1-25. doi: 10.1007/s10566-02109653-x. epub ahead of print. pmid: 34602804; pmcid: pmc8477975. 5. sauer, l. (2022, february 24). what is coronavirus? john hopkins medicine. https://www.hopkinsmedicine.org/health/co nditions-and-diseases/coronavirus 6. national institute of mental health. (2018, february). depression. national institute of mental health. https://www.nimh.nih.gov/health/topics/depr ession 7. national institute of mental health. (2019). anxiety disorders. nih.gov; national institute of mental health. https://www.nimh.nih.gov/health/topics/anxi ety-disorders 8. banati p, idele p. addressing the mental and emotional health impacts of covid-19 on children and adolescents: lessons from hiv/aids. front psychiatry. 2021 jun 22;12:589827. doi: 10.3389/fpsyt.2021.589827. 9. singh s, roy d, sinha k, parveen s, sharma g, joshi g. impact of covid-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations. psychiatry res. 2020 nov;293:113429. doi: 10.1016/j.psychres.2020.113429. 10. kormendi nm, brown ad. asian american mental health during covid-19: a call for task-sharing interventions. ssm ment health. 2021 dec;1:100006. doi: 10.1016/j.ssmmh.2021.100006. 11. pumariega aj, jo y, beck b, rahmani m. trauma and us minority children and youth. curr psychiatry rep. 2022 apr;24(4):285-295. doi: 10.1007/s11920022-01336-1. epub 2022 mar 14. pmid: 35286562; pmcid: pmc8918907. 12. han s, riddell jr, piquero ar. anti-asian american hate crimes spike during the early stages of the covid-19 pandemic. j interpers violence. 2022 jun 3:8862605221107056. doi: 10.1177/08862605221107056. epub ahead of print. pmid: 35657278; pmcid: pmc9168424.https://doi.org/10.1177/08862 605221107056 13. macias gil r, marcelin jr, zuniga-blanco b, marquez c, mathew t, piggott da. covid-19 pandemic: disparate health impact on the hispanic/latinx population in the united states. j infect dis. 2020 oct 13;222(10):1592-1595. doi: 10.1093/infdis/jiaa474. pmid: 32729903; pmcid: pmc7454709. 14. raymond-flesch m, browne en, auerswald c, minnis am. family and school connectedness associated with lower depression among latinx early adolescents in an agricultural county. am j community psychol. 2021 sep;68(1-2):114-127. doi: 10.1002/ajcp.12499. epub 2021 feb 3. pmid: 33534150; pmcid: pmc8329104. 15. united nations. (2020). policy brief: the impact of covid-19 on children https://unsdg.un.org/sites/default/files/202004/160420_covid_children_policy_brief.p df special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.66 dhr proceedings ǀ http://dhrproceedings.org 49 2022, vol. 2 no. s2 49-54 commentary type 2 diabetes and its effect on the elderly population gonzalo aleman 1, 2, mayte aleman 1, 2, vicente garcia 1, 2, brisaeda guerrero 1, 2 mareli cuellar 1, 3, brandy guerrero 1, 3, meranda martinez 1, 3 1 2ndannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2 los fresnos high school, los fresnos, tx 3 weslaco east high school, weslaco, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/21/2022 accepted for publication 08/03/2022 published 08/03/2022 introduction in 1500 b.c, egyptians’ scripts helped researchers discover that indian doctors called diabetes, madhumeha, since ants were attracted to urine from certain individuals [1]. later in 400-500 a.d, indian physician, sushruta, and surgeon, charaka, recognized that there were two types, type i and type ii diabetes [1]. in 1978, british surgeon, john rollo, originated the word mellitus, which helped him discover that diabetes had another attribute, diabetes insipidus [1]. diabetes insipidus is the creation of enormous amounts of weak, thin urine due to the kidneys not properly concentrating the urine, which is mostly produced because of dehydration and thirst [2]. however, diabetes mellitus (type i & type ii) is when the pancreas can’t generate enough insulin to manage glucose levels in the blood [2]. in type i diabetes, the pancreas isn’t making the right amount of insulin to help the glucose stabilize and enter the cell [2]. individuals with type i diabetes develop symptoms such as losing weight, urinating a lot, and being very thirsty [3]. type ii diabetes is a more complicated disorder that includes the pancreas, insulin system, liver, kidneys, gut, muscle, fat cells, and brain [4]. type ii diabetes symptoms are increased thirst, fatigue, blurred vision, and extreme weight loss [5]. type ii diabetes type ii diabetes has affected the population with high rates of diabetes-related morbidity and mortality. type ii diabetes is a chronic disease in which your blood glucose is high. glucose is the main source of energy that comes from the food that someone eats [6]. a hormone called insulin helps the cells receive energy from the glucose, but over time having a lot of glucose in your blood can cause health problems. some health problems that elderly people can develop are heart disease, kidney disease, dental disease, and nerve damage. development and symptoms of type ii diabetes type ii diabetes may be caused by being overweight, not being physically active, or the genetics of your family. having extra weight can cause insulin resistance and type ii diabetes usually starts with insulin resistance. insulin resistance is when cells in the muscles, fat, and liver don’t respond well to https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3749019/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3749019/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3749019/ https://pubmed.ncbi.nlm.nih.gov/8575409/ https://pubmed.ncbi.nlm.nih.gov/8575409/ https://pubmed.ncbi.nlm.nih.gov/8575409/ https://www.cdc.gov/diabetes/basics/what-is-type-1-diabetes.html https://pubmed.ncbi.nlm.nih.gov/27262256/ https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193 https://medlineplus.gov/diabetestype2.html#cat_95 aleman, et al. type 2 diabetes in elderly https://doi.org/10.47488/dhrp.v2is2.66 dhr proceedings ǀ http://dhrproceedings.org 50 2022, vol. 2 no. s2 49-54 insulin and can’t easily take up glucose from the blood [7]. as a result, the pancreas makes more insulin to make the cells receive the glucose it needs. over time, the pancreas will not be able to make enough insulin and the blood glucose levels will rise [7]. type ii diabetes symptoms include an increase in hunger, thirst, and urination. it also includes blurred vision, sores that don’t heal, and numbness or tingling in the feet or hands [8]. risk factors of type ii diabetes type ii diabetes affects all people around the world, including, hispanics/latinos, african americans, and alaska natives. this is due to genetic, environmental, and metabolic risk factors. the majority of the population has been at high risk of developing type ii diabetes because of poor alimentation and physical inactivity. genetics and lifestyle are the main risk factors that lead to the development of type ii diabetes. people with insulin resistance can have the same risk factors as type ii diabetes patients. the development of risk factors can help individuals have early detection and treatment and reduce later complications. [9-10]. type ii diabetes diagnosis type ii diabetes is diagnosed to help individuals reduce and manage the glucose levels in the body. it is diagnosed by taking blood tests which help the doctors determine if blood sugar is high or low. there are four different tests that can evaluate the blood glucose level: a1c, fasting plasma glucose (fpg), oral glucose tolerance test (ogtt), and random plasma glucose test. the a1c test calculates the blood sugar from the previous two or three months [11]. the a1c test is a blood test where blood is drawn from the vein in your arm and then they are sent to a lab for analysis [12]. the fasting plasma glucose test examines the glucose by not having anything to eat or drink for a minimum of 8 hours before the test and this test is done in the morning prior to breakfast [11]. the oral glucose tolerance test checks the blood glucose levels before and two hours after drinking a high-sugary drink which helps the doctor determine the way your body metabolizes sugar [11]. the random plasma glucose test is tested on individuals that have critical diabetes symptoms and is diagnosed at any moment throughout the 7day [11]. in addition, this test is done by a puncture in the finger to draw a small amount of blood and is then put onto a test strip which will give the glucose levels [13]. prevalence of type ii diabetes diabetes is a worldwide epidemic, affecting 415 million people and about 193 million undiagnosed [14]. it affects 25% of the population of people over the age of 65, and the percentage continues to increase rapidly [15]. according to the american diabetes association, in 2019, 37.3 million americans, or 11.3% of the population had diabetes. the percentage of americans 65 and older remains high at 29.2% or 15.9 % of million seniors (diagnosed and undiagnosed, respectively) [16]. in the united states, diabetes is the seventh leading cause of death, and approximately 95% percent of 37 million americans have type ii diabetes [17-18]. among these patients, adults over 65 years of age are more prevalent to develop type ii diabetes because of natural insulin decrease. the rates of type ii diabetes steadily increase in age, but it can be developed at any time. it is important to be aware of the circumstances and symptoms of type ii diabetes, whether you’re healthy or not. managing diabetes is crucial because it can cause serious health problems over time like heart disease, stroke, kidney disease, eye problems, and nerve damage that can possibly lead to amputation. along with health problems, patients with type ii diabetes have a greater risk for cancer and alzheimer’s disease [19]. living in a state that has one of the highest rates of diabetes that constantly exceeds the national average, texas, the concern on diabetes is a constant issue [17]. in addition, the circumstances of living in an area that has the highest rates of obesity in the country comes with many health concerns, along with the prevalence of diabetes [20]. the rio grande valley faces a burden of high rates of diabetes that are almost three times as high as the general population of the united states [21]. a study from utrgv compared diabetes prevalence in the rio grande valley’s four counties with the united states between the years 2004-2017 [22]. results show that the prevalence of diabetes in the united states increased by 1.5% while the rio grande valley’s prevalence increased by 6.33%. the highest increase within the rio grande valley was in willacy county with an increase of 11.6%. the study did not differentiate between the 2 types of diabetes, however, 95% of the diabetic cases account for type ii diabetes [22]. on the other hand, the rio grande valley is populated by 91.5% of hispanics, as of 2019, and statistics from the cdc show that hispanic or latino people are 17% more likely to develop type 2 diabetes https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/prediabetes-insulin-resistance https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/prediabetes-insulin-resistance https://www.niddk.nih.gov/health-information/diabetes/overview/symptoms-causes#type https://www.niddk.nih.gov/health-information/diabetes/overview/risk-factors-type-2-diabetes https://journals.lww.com/jcnjournal/abstract/2002/01000/risk_factors_for_type_2_diabetes_mellitus.3.aspx https://www.diabetes.org/diabetes/a1c/diagnosis https://www.niddk.nih.gov/health-information/diagnostic-tests/a1c-test https://www.diabetes.org/diabetes/a1c/diagnosis https://www.diabetes.org/diabetes/a1c/diagnosis https://www.diabetes.org/diabetes/a1c/diagnosis https://www.healthline.com/health/type-2-diabetes/random-glucose-testing#:~:text=it's%20usually%20done%20by%20pricking,the%20disease%20is%20being%20managed. https://pubmed.ncbi.nlm.nih.gov/28190580/ https://pubmed.ncbi.nlm.nih.gov/21890292/ https://www.diabetes.org/about-us/statistics/about-diabetes https://txohc.org/communication/data-dashboard/diabetes/#:~:text=according%20to%20the%20u.s.%20diabetes,%25%20and%20wichita%20at%2012.3%25 https://www.cdc.gov/diabetes/basics/type2.html#:~:text=healthy%20eating%20is%20your%20recipe,them%20have%20type%202%20diabetes https://www.nia.nih.gov/health/diabetes-older-people#:~:text=it's%20important%20to%20manage%20diabetes,for%20cancer%20and%20alzheimer's%20disease https://txohc.org/communication/data-dashboard/diabetes/#:~:text=according%20to%20the%20u.s.%20diabetes,%25%20and%20wichita%20at%2012.3%25 https://shmabstracts.org/abstract/obesity-and-in-patient-hospital-covid-19-outcomes-in-the-rio-grande-valley-of-texas/#:~:text=additionally%2c%20the%20rgv%20has%20one,to%20the%20high%20mortality%20rate https://www.valleycentral.com/news/local-news/rate-of-diabetes-in-the-rgv-remains-high-health-officials-urging-healthy-habits/#:~:text=photo https://scholarworks.utrgv.edu/som8127/4/ https://scholarworks.utrgv.edu/som8127/4/ aleman, et al. type 2 diabetes in elderly https://doi.org/10.47488/dhrp.v2is2.66 dhr proceedings ǀ http://dhrproceedings.org 51 2022, vol. 2 no. s2 49-54 than non-hispanic people, which is 8% [23-24]. along with a higher risk, hispanic or latino adults have a more than 50% chance of developing type ii diabetes [24]. the same study from utrgv displays another comparison on the prevalence of diagnosed diabetes in the united states between hispanic and non-hispanic white, black, and asian race-ethic groups. the outcome of the study shows that hispanics have one of the highest prevalence among the race-ethnic groups with an increase of 2.4% [22]. the statistics highlight the importance of continuing to evaluate all populations; specifically, the elderly who are affected by type ii diabetes. frailty in elderly patients with diabetes type ii diabetes in older patients has become a concern because it leads to falls, disability, hospitalization, care home admission, and even mortality [25]. elderly patients with type ii diabetes face various complications that include triopathy, retinopathy, neuropathy, nephropathy, and macrovascular complications. diabetes has been a risk factor for older people which develops a physical disability, bone fractures, cerebrovascular disease, heart disease, and hypertension [26]. frailty includes damage to older patients’ eyesight, physical, and mental disabilities. frailty is the loss of homeostasis and vulnerability to various stressors. the presence of frailty in a diabetic patient causes deterioration in muscle and nerve function [26]. frailty is not only the physical incompetence of a person but also the psychological complexity. for example, patients with type ii diabetes tend to suffer from depression, stress, and poor eating habits [27]. sarcopenia is an agerelated, involuntary loss of skeletal muscle mass and strength. diabetes causes an increase in sarcopenia in older patients, it will deteriorate muscle mass and strength faster. [28] diabetic retinopathy is an eye condition that causes vision loss and blindness in people who have diabetes. symptoms of diabetic retinopathy include dark, floating spots or streaks that look like cobwebs. this is caused by blood vessels in the retina starting to bleed into the vitreous. although these spots can clear on their own, it is important to get treatment to avoid scarring. doctors test patients with diabetes using a test called fluorescein angiogram which presents pictures of the blood vessels in a retina [29]. in order to avoid diabetic retinopathy patients must manage their diabetes. keeping their blood sugar at a healthy range and consistently visiting their doctors can help them avoid getting diabetic retinopathy. older patients must maintain a regular routine of physical activity, eat healthily, and carefully follow their doctor’s instructions on insulin intake and other diabetes medicines. treatments used for diabetic retinopathy include injections, laser treatment, and eye surgery [30]. cardiovascular disease is the leading cause of death in people with type ii diabetes. people with diabetes have a greater risk of having a cvd event. the high blood sugar in type ii diabetes damages blood vessels and the nerves that control the heart. artery walls are damaged causing heart failure. [31] afflictions of type ii diabetes the elderly population with type ii diabetes can undertake a lot of disorders. a few conditions that develop due to the disease may include eye damage, skin conditions, nerve damage, and sleep apnea [32]. as blood sugar levels increase, the insulin-producing beta cells in the pancreas release more insulin, causing cells to become impaired and unable to develop enough to meet the body's demands [33]. as a result, the risk of receiving eye damage from type ii diabetes is elevated. blindness is one of the potential long-term effects because of damaged blood vessels in the retina which can eventually lead to blinding afflictions such as cataracts and glaucoma [30]. additionally, nerve damage may be caused because of high blood sugar. indication of neuropathy could be identified by tingling, numbness, burning, or loss of feeling that usually begins at the tips of toes or fingers. elders are usually likely to underestimate the damage to their diabetic foot. involving injuries leading to amputations. generally, the damage spread upward throughout one [32]. nausea, vomiting, diarrhea, or constipation are factors that may take place. in men, the damage may cause erectile dysfunction [34]. obstructive sleep apnea is a frequently common condition in people with type ii diabetes [32]. this regard sleeping disorders which repeatedly come and go. snoring loudly and feeling intriguingly tired may be signs of sleep apnea. diabetics are substantially more prone to this because of alterations made in glucose metabolism. though treating this sleeping disorder has been proven to also assist in helping your blood sugar levels [35]. https://riograndeguardian.com/new-research-shows-economic-power-of-hispanic-households-in-rgv/#:~:text=between%202010%20and%202019%2c%20the,grew%20to%2091.5%25%20in%202019 https://www.cdc.gov/diabetes/library/features/hispanic-diabetes.html#:~:text=diabetes%20affects%20hispanic%20or%20latino,it%20at%20a%20younger%20age https://www.cdc.gov/diabetes/library/features/hispanic-diabetes.html#:~:text=diabetes%20affects%20hispanic%20or%20latino,it%20at%20a%20younger%20age https://scholarworks.utrgv.edu/som8127/4/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8099963/ https://pubmed.ncbi.nlm.nih.gov/29238004/ https://pubmed.ncbi.nlm.nih.gov/29238004/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6166557/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4066461/ https://pubmed.ncbi.nlm.nih.gov/28412095/ https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/diabetic-retinopathy#:~:text=diabetic%20retinopathy%20is%20the%20most,more%20likely%20to%20develop%20cataracts. https://pubmed.ncbi.nlm.nih.gov/29669543/ https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193 https://medlineplus.gov/ency/article/000305.htm#:~:text=without%20enough%20insulin%2c%20glucose%20builds,symptoms%20of%20type%201%20diabetes https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/diabetic-retinopathy https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193 https://pubmed.ncbi.nlm.nih.gov/22911959/ https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193 https://www.mayoclinic.org/diseases-conditions/sleep-apnea/symptoms-causes/syc-20377631#:~:text=sleep%20apnea%20is%20a%20potentially,occurs%20when%20throat%20muscles%20relax aleman, et al. type 2 diabetes in elderly https://doi.org/10.47488/dhrp.v2is2.66 dhr proceedings ǀ http://dhrproceedings.org 52 2022, vol. 2 no. s2 49-54 treatments for type 2 diabetes treatment for type ii diabetes has been helpful in many patients. elderly patients have been exposed to a variety of treatment options that are continuously being studied. common non-insulin antidiabetic drugs such as, “biguanides,” sulfonylureas, and thiazolidinediones, are, however, the most cost-effective treatments used on elderly patients [36]. metformin is a significant drug used in the treatment of type ii diabetes. it is effective in lowering blood glucose, increasing insulin sensitivity, and reducing cardiovascular and hypoglycemia risk [36]. the main use of metformin is that it can treat hyperglycemia in type 2 diabetes and the improvement of glycemic control [37]. an addition to the medication is the importance of activating ampactivated protein kinase (ampk) and interpreting hepatic gluconeogenic genes and decreasing the development of impaired glucose in patients, with metformin, however, it stimulates ampk which signals mediated cancer cell apoptosis, and if the metformin isn’t given gluconeogenesis will come into lay and suppress ampk and atp production for the cells which would worsen the type ii diabetes [38]. it is, however, cautiously used in elderly diabetic patients with the concerns of them having lactic acidosis, gastrointestinal effects such as nausea, vomiting, diarrhea, flatulence, the reduction of calorie intake, and extreme weight loss [36]. sulfonylureas are a recommended second line of treatment, however, it is commonly used as a first. sulfonylureas directly islet b cells to closed atp-sensitive k+ channels and stimulate the secretion of insulin [36]. there are more cardiovascular effects that come into play when taking sulfonylureas. even though it is a cautious drug that should not be used a lot, its medication helps with the treatment of type ii diabetes [39]. the drug is cost-effective; however, it increases higher risks of ischemic stroke, cardiovascular death, and all-cause mortality in matched cohorts [39]. although the use of sulfonylureas is still common in everyday medicine, doctors are cautious when prescribing the medication to patients. thiazolidinediones is a type of insulin sensitizer, including troglitazone, rosiglitazone, and pioglitazone. it is a receptor that controls normal skeletal muscle and hepatic insulin sensitivity. the action of thiazolidinediones is to regulate hyperglycemia than sulfonylureas and metformin and does not increase the risk of hyperglycemia [36]. the three treatments of tzd pioglitazone, rosiglitazone, and troglitazone are effective in elderly patients but should be used cautiously with some health defects occurring when on the medication [36]. pioglitazone is well treated in elderly patients with renal impairments and type ii diabetes, and it does not cause hypoglycemia, however, it should be avoided in patients with congestive or class ⅲ-ⅳ heart failure. unlike, pioglitazone, rosiglitazone and troglitazone are medications for tzd that have been removed from any pharmacy market, due to patients increased risk of myocardial infarction and idiosyncratic hepatotoxicity [36]. conclusion type ii diabetes has caused many downfalls in the history of humanity, especially for the elderly. almost 30 percent of the united states population over the age of 65 have been diagnosed with this type ii diabetes and as a result, caused harm to the elderly patient [40]. complications in an elderly patient with type ii diabetes can be severe especially if they are over the age of 65; in some cases, the alarming signs can help the patient identify type ii diabetes in time so that they are able to treat it properly [41]. in some cases, it may be difficult to recognize any signs or symptoms. this may delay finding excellent and helpful treatment in time to treat this type ii diabetes [14]. over the years, research has shown that type ii diabetes can cause severe harm to a patient and even death if not treated with time. each year the incidence keeps rising in the elderly population. for many elderly individuals, type ii diabetes can be manageable. [17]. this has become an important issue particularly in texas and in the rio grande valley because of our hispanic population and the increased number of elderlies with type ii diabetes. this is why we need more research to be done and tailored medical care so that we can be able to get better treatment based on the research results. https://pubmed.ncbi.nlm.nih.gov/25249787/ https://pubmed.ncbi.nlm.nih.gov/25249787/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7552083/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5552828/ https://pubmed.ncbi.nlm.nih.gov/25249787/ https://pubmed.ncbi.nlm.nih.gov/25249787/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6783602/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6783602/ https://pubmed.ncbi.nlm.nih.gov/25249787/ https://pubmed.ncbi.nlm.nih.gov/25249787/ https://pubmed.ncbi.nlm.nih.gov/25249787/ https://pubmed.ncbi.nlm.nih.gov/30903688/ https://pubmed.ncbi.nlm.nih.gov/25700588/ https://pubmed.ncbi.nlm.nih.gov/28190580/ https://txohc.org/communication/data-dashboard/diabetes/#:~:text=according%20to%20the%20u.s.%20diabetes,%25%20and%20wichita%20at%2012.3%25 aleman, et al. type 2 diabetes in elderly https://doi.org/10.47488/dhrp.v2is2.66 dhr proceedings ǀ http://dhrproceedings.org 53 2022, vol. 2 no. s2 49-54 acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. lakhtakia r. the history of diabetes mellitus. sultan qaboos univ med j. 2013 aug;13(3):368-70. doi: 10.12816/0003257. epub 2013 jun 25. pmid: 23984020; pmcid: pmc3749019. [pmc free article] [pubmed] 2. robertson gl. diabetes insipidus. endocrinol metab clin north am. 1995 sep;24(3):549-72. pmid: 8575409. [pubmed] 3. what is type 1 diabetes? (2022, march 11). cdc. retrieved july 18, 2022 [cdc] 4. brunton s. pathophysiology of type 2 diabetes: the evolution of our understanding. j fam pract. 2016 apr;65(4 suppl):supp_az_0416. pmid: 27262256. [pubmed] 5. type 2 diabetes symptoms and causes. (2021, january 20). mayo clinic. retrieved july 20, 2022, from [mayoclinic] 6. “type 2 diabetes| adult-onset diabetes | medlineplus.” type 2 diabetes| adult-onset diabetes | medlineplus, medlineplus.gov, 28 may 2021. [nih] date accessed 18 july 2022 7. “insulin resistance & prediabetes | niddk.” national institute of diabetes and digestive and kidney diseases, www.niddk.nih.gov, 1 may 2018. [nih] date accessed 18 july 2022 8. “symptoms & causes of diabetes | niddk.” national institute of diabetes and digestive and kidney diseases, www.niddk.nih.gov, 1 dec. 2016. [nih] date accessed 18 july 2022 9. risk factors for type 2 diabetes | niddk. (n.d.). national institute of diabetes and digestive and kidney diseases. retrieved july 18, 2022, from [nih] 10. fletcher, barbara rn, mn, faan; gulanick, meg phd, rn; lamendola, cindy rn, msn, anp risk factors for type 2 diabetes mellitus, the journal of cardiovascular nursing: january 2002 volume 16 issue 2 p 17-23 [google scholar] [the journal of cardiovascular nursing] 11. diagnosis | ada. (n.d.). american diabetes association. retrieved july 18, 2022, from [ada] 12. the a1c test & diabetes | niddk. (n.d.). national institute of diabetes and digestive and kidney diseases. retrieved july 20, 2022, from [nih] 13. random glucose testing: why it's important. (n.d.). healthline. retrieved july 20, 2022, from [healthline] 14. chatterjee s, khunti k, davies mj. type 2 diabetes. lancet. 2017 jun 3;389(10085):2239-2251. doi: 10.1016/s0140-6736(17)30058-2. epub 2017 feb 10. erratum in: lancet. 2017 jun 3;389(10085):2192. pmid: 28190580. 15. soe k, sacerdote a, karam j, bahtiyar g. management of type 2 diabetes mellitus in the elderly. maturitas. 2011 oct;70(2):151-9. doi: 10.1016/j.maturitas.2011.07.006. epub 2011 sep 3. pmid: 21890292. 16. statistics about diabetes. ada. [ada]. date accessed 19 july 2022 17. diabetes in texas. cdc. [cdc]. date accessed 19 july 2022 18. type 2 diabetes. cdc. [cdc]. date accessed 19 july 2022 19. diabetes in older people. nih-national institute on aging. [nih]. date accessed 19 july 2022 20. chen, l; masood, a; khaddam, a; chen, a; kwang, h. obesity and in-patient hospital covid-19 outcomes in the rio grande valley of texas. abstract published at shm converge 2021. abstract 55 journal of hospital medicine. https://shmabstracts.org/abstract/obesityand-in-patient-hospital-covid-19-outcomesin-the-rio-grande-valley-of-texas/. july 19th, 2022. 21. abril preciado. rate of diabetes in the rgv remains high, health officials urging health habits. cbs 4 news. nov 16, 2018.[valley central]. date accessed 19 july 2022 22. reid-gordon, christopher, "report on the diabetes status in the rio grande valley" (2021). medi 8127 scholarly activities prehttps://www.ncbi.nlm.nih.gov/pmc/articles/pmc4707300/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8548832/#b1 https://pubmed.ncbi.nlm.nih.gov/8575409/ https://www.cdc.gov/diabetes/basics/what-is-type-1-diabetes.html https://pubmed.ncbi.nlm.nih.gov/27262256/ https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193 https://medlineplus.gov/diabetestype2.html#cat_95 https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/prediabetes-insulin-resistance https://www.niddk.nih.gov/health-information/diabetes/overview/symptoms-causes https://www.niddk.nih.gov/health-information/diabetes/overview/risk-factors-type-2-diabetes https://scholar.google.com/scholar?hl=en&as_sdt=0%2c44&q=https%3a%2f%2fjournals.lww.com%2fjcnjournal%2fabstract%2f2002%2f01000%2frisk_factors_for_type_2_diabetes_mellitus.3.aspx&btng= https://scholar.google.com/scholar?hl=en&as_sdt=0%2c44&q=https%3a%2f%2fjournals.lww.com%2fjcnjournal%2fabstract%2f2002%2f01000%2frisk_factors_for_type_2_diabetes_mellitus.3.aspx&btng= https://journals.lww.com/jcnjournal/abstract/2002/01000/risk_factors_for_type_2_diabetes_mellitus.3.aspx https://journals.lww.com/jcnjournal/abstract/2002/01000/risk_factors_for_type_2_diabetes_mellitus.3.aspx https://www.diabetes.org/diabetes/a1c/diagnosis https://www.niddk.nih.gov/health-information/diagnostic-tests/a1c-test https://www.healthline.com/health/type-2-diabetes/random-glucose-testing#:~:text=it%27s%20usually%20done%20by%20pricking,the%20disease%20is%20being%20managed. https://www.diabetes.org/about-us/statistics/about-diabetes https://txohc.org/communication/data-dashboard/diabetes/#:~:text=according%20to%20the%20u.s.%20diabetes,%25%20and%20wichita%20at%2012.3%25 https://www.cdc.gov/diabetes/basics/type2.html#:~:text=healthy%20eating%20is%20your%20recipe,them%20have%20type%202%20diabetes https://www.nia.nih.gov/health/diabetes-older-people#:~:text=it%27s%20important%20to%20manage%20diabetes,for%20cancer%20and%20alzheimer%27s%20disease https://www.valleycentral.com/news/local-news/rate-of-diabetes-in-the-rgv-remains-high-health-officials-urging-healthy-habits/#:~:text=photo https://www.valleycentral.com/news/local-news/rate-of-diabetes-in-the-rgv-remains-high-health-officials-urging-healthy-habits/#:~:text=photo aleman, et al. type 2 diabetes in elderly https://doi.org/10.47488/dhrp.v2is2.66 dhr proceedings ǀ http://dhrproceedings.org 54 2022, vol. 2 no. s2 49-54 clerkship. 4. https://scholarworks.utrgv.edu/som8127/4 23. dayna reyes. new research shows the economic power of hispanic households in rgv. rio grande guardian-border business. june 7, 2022. [rio grande guardian]. date accessed 19 july 2022. 24. hispanic or latino people and type 2 diabetes. cdc. [cdc]. date accessed 19 july 2022 25. yanase t, yanagita i, muta k, nawata h. frailty in elderly diabetes patients. endocr j. 2018 jan 30;65(1):1-11. doi: 10.1507/endocrj. ej17-0390. epub 2017 dec 14. pmid: 29238004. 26. strain wd, down s, brown p, puttanna a, sinclair a. diabetes and frailty: an expert consensus statement on the management of older adults with type 2 diabetes. diabetes ther. 2021 may;12(5):1227-1247. doi: 10.1007/s13300-021-01035-9. epub 2021 apr 8. pmid: 33830409; pmcid: pmc8099963. 27. yanase t, yanagita i, muta k, nawata h. frailty in elderly diabetes patients. endocr j. 2018 jan 30;65(1):1-11. doi: 10.1507/endocrj. ej17-0390. epub 2017 dec 14. pmid: 29238004. 28. lechner j, o'leary oe, stitt aw. the pathology associated with diabetic retinopathy. vision res. 2017 oct; 139:7-14. doi: 10.1016/j.visres.2017.04.003. epub 2017 apr 29. pmid: 28412095. 29. kalra s, jena bn, yeravdekar r. emotional and psychological needs of people with diabetes. indian j endocrinol metab. 2018 sep-oct;22(5):696-704. doi: 10.4103/ijem.ijem_579_17. pmid: 30294583; pmcid: pmc6166557. 30. walston jd. sarcopenia in older adults. curr opin rheumatol. 2012 nov;24(6):623-7. doi: 10.1097/bor.0b013e328358d59b. pmid: 22955023; pmcid: pmc4066461. 31. strain wd, paldánius pm. diabetes, cardiovascular disease, and the microcirculation. cardiovasc diabetol. 2018 apr 18;17(1):57. doi: 10.1186/s12933-0180703-2. erratum in: cardiovasc diabetol. 2021 jun 11;20(1):120. pmid: 29669543; pmcid: pmc5905152. 32. mayo clinic staff. type 2 diabetes. mayo clinic. jan. 20, 2021. [mayo clinic] date accessed 21 july 2022. 33. type 1 diabetes. medline plus. [medline plus] date accessed 21 july 2022. 34. habibi a, kalbasi s, saadatjoo sa, arefi mg. evaluation of erectile dysfunction and associated factors in type-ii diabetic patients in birjand, iran in 2008-2009. j res health sci. 2011 nov 4;11(2):97-102. pmid: 22911959. 35. mayo clinic staff. sleep apnea. mayo clinic. jul. 28, 2020 [mayo clinic] date accessed 21 july 2022. 36. wu y, ding y, tanaka y, zhang w. risk factors contributing to type 2 diabetes and recent advances in the treatment and prevention. int j med sci. 2014 sep 6;11(11):1185-200. doi: 10.7150/ijms.10001. pmid: 25249787; pmcid: pmc4166864. 37. filion kb, douros a, azoulay l, yin h, yu oh, suissa s. sulfonylureas as initial treatment for type 2 diabetes and the risk of adverse cardiovascular events: a populationbased cohort study. br j clin pharmacol. 2019 oct;85(10):2378-2389. doi: 10.1111/bcp.14056. epub 2019 jul 31. pmid: 31276600; pmcid: pmc6783602. 38. flory j, lipska k. metformin in 2019. jama. 2019 may 21;321(19):1926-1927. doi: 10.1001/jama.2019.3805. pmid: 31009043; pmcid: pmc7552083. 39. rena g, hardie dg, pearson er. the mechanisms of action of metformin. diabetologia. 2017 sep;60(9):1577-1585. doi: 10.1007/s00125-017-4342-z. epub 2017 aug 3. pmid: 28776086; pmcid: pmc5552828. 40. leroith d, biessels gj, braithwaite ss, casanueva ff, draznin b, halter jb, hirsch ib, mcdonnell me, molitch me, murad mh, sinclair aj. treatment of diabetes in older adults: an endocrine society* clinical practice guideline. j clin endocrinol metab. 2019 may 1;104(5):15201574. doi: 10.1210/jc.2019-00198. pmid: 30903688; pmcid: pmc7271968. 41. bansal n, dhaliwal r, weinstock rs. management of diabetes in the elderly. med clin north am. 2015 mar;99(2):351-77. doi: 10.1016/j.mcna.2014.11.008. epub 2014 dec 30. pmid: 25700588. https://riograndeguardian.com/new-research-shows-economic-power-of-hispanic-households-in-rgv/#:~:text=between%202010%20and%202019%2c%20the,grew%20to%2091.5%25%20in%202019 https://riograndeguardian.com/new-research-shows-economic-power-of-hispanic-households-in-rgv/#:~:text=between%202010%20and%202019%2c%20the,grew%20to%2091.5%25%20in%202019 https://www.cdc.gov/diabetes/library/features/hispanic-diabetes.html#:~:text=diabetes%20affects%20hispanic%20or%20latino,it%20at%20a%20younger%20age https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193 https://medlineplus.gov/ency/article/000305.htm#:~:text=without%20enough%20insulin%2c%20glucose%20builds,symptoms%20of%20type%201%20diabetes https://medlineplus.gov/ency/article/000305.htm#:~:text=without%20enough%20insulin%2c%20glucose%20builds,symptoms%20of%20type%201%20diabetes https://www.mayoclinic.org/diseases-conditions/sleep-apnea/symptoms-causes/syc-20377631#:~:text=sleep%20apnea%20is%20a%20potentially,occurs%20when%20throat%20muscles%20relax special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.48 dhr proceedings ǀ http://dhrproceedings.org 15 2022, vol. 2 no. s2 15-19 commentary the effects of alzheimer’s disease: gender, race, & ethnicity kenya a. rodriguez1,2, selena aleman1,3, hannah e. rodriguez1,3, allison r. alvarez1,4, jorge s. garzapalacios1,5, marcela trevino1,6, galilea castro1,7, nahre m. j. royal1,8, grace ortiz1,9 1 2nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2 the science academy of south texas, mercedes, tx. 3 san benito high school, san benito, tx. 4 harlingen high school south, harlingen, tx. 5 edinburg north high school, edinburg, tx. 6 psja southwest echs, pharr, tx. 7 mission collegiate high school, mission, tx. 8 harlingen high school, harlingen, tx. 9 port isabel high school, port isabel, tx. all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 06/27/2022 accepted for publication 07/14/2022 published 07/14/2022 keywords: alzheimer’s disease; dementia; gender; race; hispanics; african americans; behavior introduction alzheimer’s is the most common form of dementia, a term which stems from latin that refers to, “a state out of mind” [1]. dementia has been around since ancient times and has been routinely classified as a condition of old age. individuals with dementia were often seen in an almost age reversing process, as their mental state diminished to an infant-like level. as more studies of dementia have progressed, questions have been raised over whether or not the condition is truly age-bound. alzheimer’s disease (ad) dementia is the term used for diseases that impair cognitive abilities. alzheimer’s is a form of dementia and is the sixth leading cause of death in the us. this brain disorder can occur in two age groups; there are those that experience early onset between their 30’s to 60’s and others experience onset between the mid 60’s to late 80’s [2]. a major indicator of alzheimer’s is mild cognitive impairment (mci), an early stage of memory loss. not everyone with this diagnosis develops alzheimer’s, but it is a common indicator. neurological mechanisms are affected when you have ad and, unfortunately, the damage is widespread. neurons stop functioning and lose connection with other neurons and eventually die. over time, individuals with ad slowly lose their ability to function independently due to lack of brain cell communication. rodriguez, et al effects of alzheimer’s disease https://doi.org/10.47488/dhrp.v2is2.48 dhr proceedings ǀ http://dhrproceedings.org 16 2022, vol. 2 no. s2 15-19 disease progression & effects of ad on patients the brains of individuals with ad show signs of moderate atrophy of the limbic lobe structure which affects consciousness and emotional state. the lobe is responsible for communication to other parts of the brain and for fight or flight responses. thus, when the lobe is atrophied, the loss of cells causes impairment of individuals and sporadic behaviors [3]. taking alzheimer's disease’s neuropathology as an example, memory loss is one of the first symptoms that patients with alzheimer's disease report. working memory, long-term memory, and declarative memory are all impacted in the early stages of the disease. alzheimer’s progresses gradually depending on the level of severity the individual encounters. diagnosis of alzheimer’s is difficult, and because there is no cure, treating the disease is difficult. people who develop ad become disoriented, confused, unable to tell time, recognize people, or recall recent events. individuals with ad lose brain function gradually and forget how to perform tasks that require the use of cognitive skills. this includes reading, writing, speaking, and understanding. as to why ad patients start to lose these skills, the nih has stated that “alzheimer’s disease causes brain cells to die, so the brain works less well over time. this changes how a person acts” [4]. aggression is one of the most common behaviors exhibited in individuals. wandering, paranoia, confusion, and hallucinations are also common developments [5]. as the disease progresses, these behavioral changes will also begin to amplify within the individual. the rate at which the individual is lucid (aware) also becomes less frequent and conditions tend to worsen with time. ad has an impact not just on the individual but also on the people around them. family members must deal with work-related stress, such as the need to change their schedule because they are caring for a loved one. according to a recent study, 57% of caregivers had to work late, leave early, or take time off; 16% had to miss work, 18% had to switch from full-time to parttime employment. in another study, 9% had to quit their job completely, and 6% had to retire early [6]. as a result, family members stop caring for their loved ones, which leads to individuals with ad being placed in long-term care facilities, or causing ad to progress into severe stages at faster rates because there is no available caretaker. alzheimer’s in america: race & ethnicity the occurrence of ad in people aged 65 or older is about 1 in 10. however, minorities tend to develop ad at an alarming rate. race and ethnicity are vast risk factors for developing ad. the cdc states in preceding order that, "... african americans (13.8 %), followed by hispanics (12.2 %) ..." are more prone to developing ad. the cdc even stated that, “by 2060…there will be [an estimated] 3.2 million hispanics and 2.2 million african americans with ad” [7]. factors that may be contributing to this disparity are high blood pressure and diabetes which are more prevalent in these communities. both conditions contribute to a greater prevalence of ad because blood vessels in the brain are more susceptible to damage due to hypertension [8]. data has also shown that blacks are about two times more likely than whites to have ad, while hispanics are about 1.5 times more likely. black individuals are also more likely to experience delusions, hallucinations, aggression, and irritability, in comparison to other race groups. gender prevalence although both men and women are able to develop ad, women have been proven to be more susceptible. of the 6 million people in the u.s. with ad, women make up more than half of this number. studies have given some explanation to this issue, expressing results that support women being at much greater risk. this may be because women live longer than men. additionally, according to harvard health publishing, “…women are twice as likely to have an autoimmune disease compared to men.” [9] on the other hand, men begin exhibiting signs of lucidity before women. in essence, women are slower to show the side effects of ad, like mental decline, compared to men. they have appeared to surpass males when conducting memory tests in the first stages of alzheimer’s [10]. however, this does in fact change as amyloid plaque, proteins which form in the creases of nerve cells, increases in females, unfortunately, so does lucidity; meaning that the disease grows exponentially faster in later stages of ad in women [11]. rodriguez, et al effects of alzheimer’s disease https://doi.org/10.47488/dhrp.v2is2.48 dhr proceedings ǀ http://dhrproceedings.org 17 2022, vol. 2 no. s2 15-19 diagnosis there is no way to know if an individual truly has ad. the only accurate way to diagnose an individual is post-mortem during autopsy. if an individual is diagnosed with alzheimer’s (based on symptoms and factors), the development of ad to death ranges 4-20 years [12]. treatment there is no cure for alzheimer’s disease but there are ways to slow the progression. medications are provided to people who are suffering from alzheimer’s, including cholinesterase inhibitors and memantine (namenda) which have both been approved by the fda. according to mayo clinic “...cholinesterase inhibitors boost the amount of acetylcholine available to nerve cells by preventing its [nerve cells] breakdown in the brain” [13]. this medication can slow the progression but it can’t cure ad nor stop the total destruction of nerve cells. a reported problem with this medication is loss of effectiveness over time. this is because as the disease progresses, the brain will produce less acetylcholine, a neurotransmitter of the parasympathetic nervous system that plays a role in memory, learning, and neuroplasticity. the side effects consist of nausea, vomiting, and diarrhea but can be combated by taking the medication with food or receiving treatment in low doses. on the other hand, memantine is used when the individual is in the late, severe stages of ad. the medication is used for people who are older because the drug regulates glutamate, “a messenger protein widely involved in brain functions including learning and memory” [14]. memantine is an effective medication as it is said to improve memory; however, side effects include body aches, dizziness, constipation and headaches. research & new findings the current understanding of alzheimer’s disease is limited, and there is no early diagnosis or therapy currently available. nonetheless, it is agreed that the causes for ad include increasing age, genetics, head injury, vascular disease, infections, and environmental conditions (exposure to heavy metals, trace metals, etc.). through the past few years, the understanding of the disease has significantly advanced (diagnosis, prevention, and treatment). but despite the significant progress that has been made, the cause of pathological changes in ad is still unknown. despite no official theory being confirmed, scientists suggest that an impairment in the cholinergic function is a major risk factor for alzheimer’s disease [15]. cholinergic medications are a category of pharmaceutical agents that act upon the neurotransmitter acetylcholine, the primary neurotransmitter within the parasympathetic nervous system (pns). others believe that an alteration in amyloid b-protein production and processing is the main initiating cause of alzheimer’s disease [16]. this is due to the fact that amyloid-b peptide is a major component of senile plaques that commonly form in brains affected by ad. because of the unknowns affiliated with ad, the number of clinical trials has increased over the last few years. of these clinical trials, stem cell therapy has been used as a disease-modifying treatment for ad. the number of studies on stem cells increased after the failure to create new drugs for alzheimer’s [17]. another clinical trial involves drug treatment of ad, and suggests that the pathological changes associated with alzheimer’s begin 2-3 decades before the first symptoms of alzheimer’s appear. based on data derived from the trials, it has been concluded that pharmacological therapy could benefit individuals in the pre-clinical stage of alzheimer’s (before the disease is diagnosed [18]. in another study, researchers have proposed that herpes simplex virus (hsv-1) can be a risk factor for the development of ad. studies conducted on mice infected with the hsv-1 have shown neurological degeneration and memory loss that is commonly affiliated with ad. in short, the study suggests that ad may have a viral origin. the study has ultimately raised hopes for a potential hsv-1 vaccine that could in turn diminish the rate at which ad is developed among the general population [19]. conclusion & discussion it is generally assumed that alzheimer's is a disease of age, but it has been learned that ad can begin as early as 30 years old [2]. however, research conducted on early-onset ad is limited as the total case makeup is not vast. in studying alzheimer’s, it has been found that the disease causes brain deterioration that results in severe diminishment. research did not discuss fully, however, the extent of damage that occurs in individuals with ad, nor the fact that deterioration of memory and changes in behavior are typically uneven and untimely. this is rodriguez, et al effects of alzheimer’s disease https://doi.org/10.47488/dhrp.v2is2.48 dhr proceedings ǀ http://dhrproceedings.org 18 2022, vol. 2 no. s2 15-19 likely due to the fact that the disease progresses in different ages among affected individuals, and that bodily functions (brain mechanisms) can be influenced by many factors (education, environment, etc.). additionally, it was found that the disease affects women more than men. this also extends to hispanic and african american minorities. in relation to women, ad likely develops more frequently because of high life expectancy. moreover, hispanic and african americans are more likely to develop ad due to predisposition to diabetes and high blood pressure. this insight has raised questions in relation to women and the rate of alzheimer’s. it is known that during pregnancy, women are likely to develop gestational diabetes due to hormonal imbalances [20]. this in turn causes high blood pressure which is a catalyst in the development of ad. women are also susceptible to hormonal imbalances which may account for deficiencies that can lead to brain dysfunction. currently there is no cure for ad, but there are medications that help with memory loss and disease progression. it was found that pharmaceutical treatments may help in the prevention of ad [18]. additionally, studies have found that ad may be linked to hsv-1 (herpes simplex virus) [19]. these findings have been backed by clinical trials and immunology of viruses in relation to cancer and other diseases. although ad does not root from one specific cause, it is anticipated that the future of treatment for the disease moves in this direction for future disease prevention. there is not one singular way to eradicate this disease in the general population, but it should be noted that education, both of individuals and the disease itself, can help decrease the occurrence of ad. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected and region one esc paths references 1. yang, h. d., kim, d. h., lee, s. b., & young, l. d. (2016). history of alzheimer's disease. dementia and neurocognitive disorders, 15(4), 115–121. https://doi.org/10.12779/dnd.2016.15.4.115 2. national institute on aging. (2021, july 8). what is alzheimer’s disease? national institute on aging. 3. torrico, t. j., & abdijadid, s. (2019, february 10). neuroanatomy, limbic system. nih.gov; statpearls publishing. https://www.ncbi.nlm.nih.gov/books/nbk5 38491/ 4. national institute on aging. (2017, may 17). managing personality and behavior changes in alzheimer's. national institute on aging. 5. cleveland clinic. (2019, march 18). alzheimer’s disease: symptoms, causes, treatments. cleveland clinic. 6. grabher b. j. (2018). effects of alzheimer disease on patients and their family. journal of nuclear medicine technology, 46(4), 335–340. 7. u.s. burden of alzheimer’s disease, related dementias to double by 2060. (2019). centers for disease control and prevention. 8. understanding the relationship between high blood pressure and type 2 diabetes. (2018, november 28). canopy health. 9. md, a. e. b. (2022, january 20). why are women more likely to develop alzheimer’s disease? harvard health. levine, h. (n.d.). women more likely than men to develop alzheimer’s. aarp. 10. what are amyloid plaques? (2014, january 17). news-medical.net. 11. hedman, s. a., fuzy, j. l., & rymer, s. a. (2018). hartman's nursing assistant care: the basics. albuquerque, new mexico: hartman publishing, inc. 111-113 12. mayo clinic staff. (2019). how alzheimer’s drugs help manage symptoms. mayo clinic. 13. mayo clinic. (2018). alzheimer’s disease diagnosis and treatment mayo clinic. mayoclinic.org. 14. mangialasche, f., solomon, a., winblad, b., mecocci, p., & kivipelto, m. (2010). alzheimer’s disease: clinical trials and drug development. the lancet neurology, 9(7), 702–716. https://doi.org/10.1016/s14744422(10)70119-8 https://doi.org/10.12779/dnd.2016.15.4.115 https://www.ncbi.nlm.nih.gov/books/nbk538491/ https://www.ncbi.nlm.nih.gov/books/nbk538491/ https://doi.org/10.1016/s1474-4422(10)70119-8 https://doi.org/10.1016/s1474-4422(10)70119-8 rodriguez, et al effects of alzheimer’s disease https://doi.org/10.47488/dhrp.v2is2.48 dhr proceedings ǀ http://dhrproceedings.org 19 2022, vol. 2 no. s2 15-19 15. sun, b.-l., li, w.-w., zhu, c., jin, w.-s., zeng, f., liu, y.-h., bu, x.-l., zhu, j., yao, x.-q., & wang, y.-j. (2018). clinical research on alzheimer’s disease: progress and perspectives. neuroscience bulletin, 34(6), 1111–1118. https://doi.org/10.1007/s12264-018-0249-z 16. kang, j. m., yeon, b. k., cho, s.-j., & suh, y.-h. (2016). stem cell therapy for alzheimer’s disease: a review of recent clinical trials. journal of alzheimer’s disease, 54(3), 879–889. https://doi.org/10.3233/jad-160406 17. briggs, r., kennelly, s. p., & o’neill, d. (2016). drug treatments in alzheimer's disease. clinical medicine, 16(3), 247–253. https://doi.org/10.7861/clinmedicine.16-3247 18. carter, c. j. (2010). alzheimer's disease: a pathogenetic autoimmune disorder caused by herpes simplex in a gene-dependent manner. international journal of alzheimer's disease, 2010, 1–17. https://doi.org/10.4061/2010/140539 19. shub, a., & lappas, m. (2020). pregestational diabetes in pregnancy: complications, management, surveillance, and mechanisms of disease-a review. prenatal diagnosis, 40(9), 1092–1098. https://doi.org/10.1002/pd.5718 https://doi.org/10.1007/s12264-018-0249-z https://doi.org/10.3233/jad-160406 https://doi.org/10.7861/clinmedicine.16-3-247 https://doi.org/10.7861/clinmedicine.16-3-247 https://doi.org/10.4061/2010/140539 https://doi.org/10.1002/pd.5718 special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.55 dhr proceedings ǀ http://dhrproceedings.org 61 2022, vol. 2 no. s2 61-66 commentary why is alzheimer’s disease more prevalent in the hispanic community? emma e. chavez1,3, sherlin a. aguirre1,2, deyanira ortiz1,2, mia g. picazo1,2, alyna a. lopez1,3, bethany g. gallardo1,3, raelyn e. morales1,2 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2santa maria high school, santa maria, tx 3raymondville early college high school, raymondville, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/01/2022 accepted for publication 08/05/2022 published 08/05/2022 keywords: alzheimer’s disease; hispanic community introduction hispanics are one of the largest and fastestgrowing populations in the us. their life expectancy will increase to age 87 by 2050, surpassing all other ethnic groups in the united states (1). there are many diseases that affect older americans however, hispanic americans are reported to have a higher risk for alzheimer's disease, making hispanics one of the largest groups of alzheimer’s disease in the country (2). latinos are one and a half times more likely to develop alzheimer’s disease than non-hispanic whites. evidence indicates that vascular disease, including diabetes, may also be a risk factor for alzheimer’s disease (1). alzheimer’s disease is an abundance of genetic and environmental factors, but with the limited research, we are far from knowing an effective treatment, a reliable way to manage it, and some prevention from getting this disease. levels of education have been shown to be a factor in those who are diagnosed with alzheimer’s. hispanics have the lowest education levels of any cultural group in the united states. one in 10 hispanic elders have no formal education and over half have 8 years or less (1). while education, or lack thereof, may not be the endall cure for alzheimer’s, the research shows that a large number of hispanics are suffering from it. about 13% of hispanics are suffering from alzheimer’s disease at this moment (3). among these, women are nearly two times more likely to be affected by alzheimer’s disease than men (3). so then begs the question, why is alzheimer’s more prevalent in the hispanic community? is it solely a lack of education, is it gender-specific, are there enough treatment options, or what does the future look like for alzheimer’s? what is alzheimer’s disease? in a world where humans are facing major health issues and viruses like covid-19, some people are lucky to survive with proper treatment and care. unfortunately, we also have other diseases such as diabetes, cancer and, especially, alzheimer’s that have no proven cure and will slowly cause death. alzheimers is a disease named after alois alzheimer; a doctor who first discovered it after a 51-year-old woman had experienced progressive memory loss (4). this woman’s story sparked an interest in alzheimer, and he started to investigate the pathology of the chavez, et al. alzheimer disease in the hispanic community https://doi.org/10.47488/dhrp.v2is2.55 dhr proceedings ǀ http://dhrproceedings.org 62 2022, vol. 2 no. s2 61-66 nervous system. his finding earned him the recognition for naming the disease after him. he witnessed how the disease caused the brain to deteriorate and eventually would cause a death in each of its’ victims. it is a progressive neurological disorder that causes the brain to shrink and kill the brain cells (5). symptoms eventually grow severe enough to interfere with daily tasks. currently, there are limited treatment options available with medications such as, cholinesterase inhibitors, which aim to increase communication between the nerve cells to try to improve the symptoms and slow down the progression (6). however, these drugs have only been approved for use in mild to moderate alzheimer’s disease. after the disease has increased, the brain becomes too damaged to combat the illness. symptomatic therapy is another form of treatment which, basically, is only a supportive care treatment that helps deal with the known symptoms but isn’t a curative treatment or prevents alzheimer's adequately. alzheimer's: signs, symptoms, risks, and its factors memories, the gift of holding onto the things we love most. that’s the one thing nobody ever wants to forget. unfortunately, having alzheimer's makes that happen. there are many other signs and symptoms besides memory loss. a lot of people don’t know the signs and how to know once it has hit you completely. risk factors the risk factors for getting alzheimer's are very common for older people (7). high cholesterol levels, high blood pressure levels, are major risk factors (7). age and gender are also some major risk factors. family history takes a very big part in this disease as well. signs the signs may not be easily recognizable because they usually start out with small instances of memory lapses. forgetting recent conversations, events, names, places, people (8). misplacing your items frequently and asking questions repeatedly is also one of the signs of this disease. another sign that that can be missed is poor judgment choices (9). the individual begins to lose the ability to make rational, informed decisions. once the individual reaches the point where decision making is affected, the disease has begun to take over. symptoms the first side effects and symptoms are memory loss and confusion like i mentioned in the beginning. there are 4 different types of symptoms, cognitive, behavioral, moods, and psychological (9). cognitive symptoms are mental denial and decline (9). the individual does not want to accept that they now have a disease and are ill. the individual will begin to have difficulty thinking and this will become more apparent in the evenings. recognizing new things will begin to become more difficult. these types of instances can become frustrating for someone experiencing symptoms of alzheimer. behavioral symptoms start to become more apparent over time. aggression, irritability, repetition of words, personality changes, and loss of appetite are all symptoms (10). moods are another symptom that become more apparent when they realize they are getting this horrible disease. anger, loneliness, tiredness, exhaustion, and depression (10). all of these symptoms lead to psychological problems. depression is one of the more common parts of alzheimer's that greatly affects the psychological outlook for the individual (10). individuals start to display signs of paranoia. having this side effect will cause the individual to not believe anyone or what they're telling you. hallucinations and delusions are also side effects of psychological symptoms. hallucinations will cause you to hear and see things that don’t exist. delusions are false beliefs that the person with alzheimer thinks is real. each of these affect the individual in many ways. while the risk factors that put people at risk are very common in hispanics, the symptoms that they begin to display may vary by gender and age. what age/gender is more prone to alzheimer's? studies show that apolipoprotein e (apoe) epsilon 4 impact is present at any and all ages between 40 and 90 years, although it disappears after age 70, and the risk of ad linked with a particular genotype alters with a gender (11) an individual has a higher chance of getting late-onset alzheimer’s if they have the epsilon4 variant of the apoe gene (11). inheriting apoe4 does not guarantee that a person will develop alzheimer's disease, it is the highest risk factor gene for the condition. according to the study, lipid abnormalities in brain cells may be the root cause of dementia (12). chavez, et al. alzheimer disease in the hispanic community https://doi.org/10.47488/dhrp.v2is2.55 dhr proceedings ǀ http://dhrproceedings.org 63 2022, vol. 2 no. s2 61-66 in comparison to males, women are more likely than men to have alzheimer's disease. the disease affects 0.7% of women and 0.6% of males between the ages of 65 and 69, and its prevalence rises to 14.2% and 8.8% in those between the ages of 85 and 89 (12). additionally, it is more common in women with dementia. in austria, women make up 74.1 percent of alzheimer's patients over 60 (12). aggression is more common in males than in women, although women have a wider range of behavioral symptoms associated with dementia, and with a predominance of sadness (13). different brain architecture and function, with a higher vulnerability for pathological lesions in women and larger cognitive reserve in men, are scientific reasons for genderspecific variations on the phenotype of alzheimer’s disease (13). additionally, there were found to be sex variations in the production of antioxidant enzymes and post-menopausal hormonal alterations (14). according to the vast majority of research conducted in the united states, well after the age of 85, there is no gender difference in the prevalence of ad dementia (14). women do seem to experience this condition more frequently in different parts of the world. the frequency of dementia varies among racial and ethnic groups in the united states, according to some of the research. despite variations in study designs, sample techniques, and definitions of dementia, it has consistently been demonstrated that african americans and hispanics are more likely to develop dementia than white people (15). alzheimer's disease has a disproportionately negative impact on women (ad). women make up almost two-thirds of the much more than 5 million americans who have alzheimer's disease, and they account for roughly two-thirds of the more than 15 million americans who provide care and assistance for someone with the illness (16). above people aged 65 make up the majority of those who have the condition. alzheimer's disease risk increases every five years beyond the age of 65. above age 85, this risk increases to over onethird. alzheimer's disease is a common cause of dementia, which affects one in six individuals over the age of 80. alzheimer's disease or related dementia affects around 13% of hispanics who are 65 or older (16). prevalence in the hispanic community for alzheimer’s disease as mentioned above, alzheimer's disease is the most common type of dementia among individuals 65 and older. several reports indicate that ad is more prevalent among latinos (17). like any other demographic group, hispanic americans have a variety of backgrounds, races, ethnicities and experiences. one-third of hispanic americans report that they have experienced discrimination when seeking health care. latinos are considered an underserved group because they are less likely to obtain regular health care services and have higher rates of chronic diseases (18). almost 85% say it is important for alzheimer’s and dementia care providers to understand their ethnic or racial background and experiences. almost 57% believe that a significant loss of memory or cognitive abilities is a normal part of aging (19). the centers for disease control and prevention (cdc) claims that by 2060 the number of latinos ages 65 and older are expected to nearly quadruple, and latinos will face the largest increase in ad (13). beyond age, there are more risks including low socioeconomic, lots of cardiovascular disease, and a higher prevalence of conditions like diabetes, high blood pressure, obesity, and depression (20). claims have been made stating that education plays a significant role in determining the risk of ad. researchers found that higher dementia prevalence among latinos compared to non-latino was associated with lower levels of education. for latinos in the study sample, those who did not complete high school had on average of only three years of education (21). even for people with just a few years of formal schooling, every additional year of education decreased dementia risk. alzheimer’ treatment currently, there are various types of treatment-based drug options for alzheimer's disease, but only 5 have been approved in the united states (22). these treatments include cholinesterase inhibitors like donepezil, galantamine, rivastigmine, and metamine (22). as of now, the most effective drug available is aducanumab. the reason behind this is that it's a type of antibody therapy that targets a certain protein in the brain that gathers in lumps. researchers believe these clumps play a role in damaging brain cells, ultimately causing the brain to stop working and become fatal (23). while it is most effective, only one of the 5 drugs approved is used to treat both mild and severe alzheimer's disease. donepezil, which is fda approved, is used for all stages of this disease. it is most commonly used to improve memory function, awareness, physical function, and thinking ability (24). although these drugs won't cure the disease, they have made a big impact on alzheimer's as a whole. chavez, et al. alzheimer disease in the hispanic community https://doi.org/10.47488/dhrp.v2is2.55 dhr proceedings ǀ http://dhrproceedings.org 64 2022, vol. 2 no. s2 61-66 another type of treatment includes combination therapy. this may involve music therapy, physical therapy, or art therapy. although, the most studied treatment has been musical therapy, due to the objective response given by patients, as a result of the treatment (25). during this treatment, a qualified music therapist evaluates a patient to mediate the treatment according to the patient at hand. for example, listening to familiar spanish songs was found to stabilize or improve the consciousness of patients with mild to severe alzheimer's disease, according to a study conducted by arroyo-anilo (25). as a result of the popularity of this treatment, different clinical trials and studies have used musical elements to treat the effects of alzheimer's. another form of musical therapy is background music. an example of this is vivaldi’s spring movement from ‘the four seasons' that was previously used during the recall tests in mild alzheimer's disease patients (25). in the study, it was found that music could improve autobiographical memory and reduce anxiety and emotions. it is unknown, however, what directly causes the effects of background music. although, researchers believe that the change in mood, such as a reduction in anxiety, is the cause, and scientists have speculated that music may enhance memory by the arousal to the sound (25). although these options are just placeholders for the cure, they play a role in future studies and possible groundbreaking discoveries. what is needed for the future of alzheimer's prevention? while scientists are still busy trying different drug treatments and alternative options, there is still much work to be done. scientists do not fully understand how cholinesterase inhibitors work to treat alzheimer's disease, but research indicates that a person living with alzheimer's may respond better to one drug versus another (26). a growing understanding of how the disease disrupts the brain has led to potential alzheimer's treatments that shortcircuit basic disease processes. future alzheimer's treatments may include a combination of medications, similar to how treatments for many cancers or hiv/aids include more than a single drug (27). the first drug that was approved by the food and drug administration (fda) in 2021 was called aducanumab (26). this drug targeted the underlying cause of alzheimer’s in patients. clinical studies to determine the effectiveness of aducanub were conducted only in people with early-stage alzheimer's or mild cognitive impairment (27). researchers are continuing to study whether this medication works to affect a person's rate of cognitive decline over time. aducanub is reported to slow the decline in cognitive skills and functional ability (26). it does this by clearing amyloid beta that builds up in the brain, which is thought to result in alzheimer's. alzheimer’s is a disease that will not disappear, but there are some ways that we can help to lower the number of people who have been diagnosed with alzheimer's. physical activity can help prevent the disease as well as aerobic exercise (27). aerobic exercise in particular may help slow shrinkage in the hippocampus, which is a spot in the brain that deals with memory. conclusion to answer the question, “why is alzheimer’s more prevalent in the hispanic community?”, one would need more extensive research. we have the data to show that the prevalence is high, but not enough to show why. there are factors such as lack of education and socioeconomic disparities that have shown to be factors, but there are not enough hispanic individuals that are participating in research studies to prove any others that are affecting them. treatments and nonmedical therapies may give the individual a slightly longer life expectancy but will not offer a cure as of yet. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. hispanics and latinos and alzheimer’s disease report. (2004). https://www.alz.org/national/documents/rep ort_hispanic.pdf 2. seifi, a., bahadori, m., eslami, v., gheibi, z., & mirahmadizadeh, a. (2021). hispanic ethnicity and in-hospital morbidity and mortality outcomes in alzheimer’s disease: chavez, et al. alzheimer disease in the hispanic community https://doi.org/10.47488/dhrp.v2is2.55 dhr proceedings ǀ http://dhrproceedings.org 65 2022, vol. 2 no. s2 61-66 a u.s. national study 2005–2015. clinical neurology and neurosurgery, 207, 106753. https://doi.org/10.1016/j.clineuro.2021.1067 53 3. hispanic americans and alzheimer’s. (2022). alzheimer’s disease and dementia.https://www.alz.org/helpsupport/resources/hispanics-andalzheimers~:text=approximately%2013%25 %20of%20hispanics%20who 4. the story of auguste deter | asc blog. (2018, august 9). senior living communities & nursing homes in indiana | asc. https://www.asccare.com/storyauguste-deter 5. alzheimer’s disease symptoms and causes. (n.d.). mayo clinic. https://www.mayoclinic.org/diseasesconditions/alzheimers-disease/symptomscauses/syc-20350447#:~:text=overview 6. how do drugs for alzheimer’s disease work? (n.d.). alzheimer’s society. https://www.alzheimers.org.uk/aboutdementia/treatments/drugs/how-do-drugsalzheimers-diseasework#:~:text=donepezil%2c%20rivastigmi ne%20and%20galantamine%20all 7. denoon, d. j. (2003, july 29). causes of alzheimer’s disease. webmd; webmd. https://www.webmd.com/alzheimers/guide/a lzheimers-causes-risk-factors 8. alzheimer’s and hallucinations, delusions, and paranoia. (2017, may 17). national institute on aging. https://www.nia.nih.gov/health/alzheimersand-hallucinations-delusions-and-paranoia 9. farrer, l. a., cupples, l. a., haines, j. l., hyman, b., kukull, w. a., mayeux, r., myers, r. h., pericak-vance, m. a., risch, n., & van duijn, c. m. (1997). effects of age, sex, and ethnicity on the association between apolipoprotein e genotype and alzheimer disease. a meta-analysis. apoe and alzheimer disease meta analysis consortium. jama, 278(16), 1349–1356. 10. schmidt, r., kienbacher, e., benke, t., dalbianco, p., delazer, m., ladurner, g., jellinger, k., marksteiner, j., ransmayr, g., schmidt, h., stögmann, e., friedrich, j., & wehringer, c. (2008). geschlechtsspezifische unterschiede der alzheimer demenz [sex differences in alzheimer's disease]. neuropsychiatrie : klinik, diagnostik, therapie und rehabilitation : organ der gesellschaft osterreichischer nervenarzte und psychiater, 22(1), 1–15. 11. farrer, l. a., cupples, l. a., haines, j. l., hyman, b., kukull, w. a., mayeux, r., myers, r. h., pericak-vance, m. a., risch, n., & van duijn, c. m. (1997). effects of age, sex, and ethnicity on the association between apolipoprotein e genotype and alzheimer disease. a meta-analysis. apoe and alzheimer disease meta analysis consortium. jama, 278(16), 1349–1356. https://pubmed.ncbi.nlm.nih.gov/9343467/ 12. schmidt, r., kienbacher, e., benke, t., dalbianco, p., delazer, m., ladurner, g., jellinger, k., marksteiner, j., ransmayr, g., schmidt, h., stögmann, e., friedrich, j., & wehringer, c. (2008). [sex differences in alzheimer’s disease]. neuropsychiatrie: klinik, diagnostik, therapie und rehabilitation: organ der gesellschaft osterreichischer nervenarzte und psychiater, 22(1), 1–15. https://pubmed.ncbi.nlm.nih.gov/18381051/ 13. schmidt, r., kienbacher, e., benke, t., dalbianco, p., delazer, m., ladurner, g., jellinger, k., marksteiner, j., ransmayr, g., schmidt, h., stögmann, e., friedrich, j., & wehringer, c. (2008). [sex differences in alzheimer’s disease]. neuropsychiatrie: klinik, diagnostik, therapie und rehabilitation: organ der gesellschaft österreichischer nervenärzte und psychiater, 22(1), 1–15. https://pubmed.ncbi.nlm.nih.gov/18381051/ 14. national center for biotechnology information. nih.gov. https://www.ncbi.nlm.nih.gov 15. alzheimer’s disease and dementia. https://www.alz.org 16. alzheimer’s society united against dementia | alzheimer’s society. alzheimers.org.uk. https://www.alzheimers.org.uk 17. brovero, d. (2016). facebook.com. https://www.facebook.com/nihaging. 18. usc roybal institute study finds latinos’ increased dementia risk linked to lower education levels. (n.d.). usc suzanne dworak-peck school of social work. retrieved june 29, 2022, from https://dworakpeck.usc.edu/news/uscroybal-institute-study-finds-latinosincreased-dementia-risk-linked-to-lowereducation#:~:text=it%20affects%20 about%205.7%20million https://doi.org/10.1016/j.clineuro.2021.106753 https://doi.org/10.1016/j.clineuro.2021.106753 https://www.alz.org/help-support/resources/hispanics-and-alzheimers~:text=approximately%2013%25%20of%20hispanics%20who https://www.alz.org/help-support/resources/hispanics-and-alzheimers~:text=approximately%2013%25%20of%20hispanics%20who https://www.alz.org/help-support/resources/hispanics-and-alzheimers~:text=approximately%2013%25%20of%20hispanics%20who https://www.alz.org/help-support/resources/hispanics-and-alzheimers~:text=approximately%2013%25%20of%20hispanics%20who https://www.asccare.com/story-auguste-deter https://www.asccare.com/story-auguste-deter https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/symptoms-causes/syc-20350447#:~:text=overview https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/symptoms-causes/syc-20350447#:~:text=overview https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/symptoms-causes/syc-20350447#:~:text=overview https://www.webmd.com/alzheimers/guide/alzheimers-causes-risk-factors https://www.webmd.com/alzheimers/guide/alzheimers-causes-risk-factors https://www.nia.nih.gov/health/alzheimers-and-hallucinations-delusions-and-paranoia https://www.nia.nih.gov/health/alzheimers-and-hallucinations-delusions-and-paranoia https://pubmed.ncbi.nlm.nih.gov/9343467/ https://pubmed.ncbi.nlm.nih.gov/18381051/ https://www.alz.org/ https://www.alzheimers.org.uk/ chavez, et al. alzheimer disease in the hispanic community https://doi.org/10.47488/dhrp.v2is2.55 dhr proceedings ǀ http://dhrproceedings.org 66 2022, vol. 2 no. s2 61-66 19. elsevier. (2019). sciencedirect.com | science, health and medical journals, full text articles and books. sciencedirect.com. https://www.sciencedirect.com/ 20. alzheimer's association. (2016). home. alzheimer’s disease and dementia. https://www.alz.org/ 21. usc suzanne dworak-peck school of social work. (n.d.). dworakpeck.usc.edu. https://dworakpeck.usc.edu/ 22. cummings jl, tong g, ballard c. treatment combinations for alzheimer's disease: current and future pharmacotherapy options. j alzheimers dis. 2019;67(3):779794. doi: 10.3233/jad-180766. pmid: 30689575; pmcid: pmc6398562. 23. what is aducanumab and what could this dementia drug mean for people with alzheimer’s disease? | alzheimer’s society. (n.d.). www.alzheimers.org.uk. https://www.alzheimers.org.uk/blog/what-isaducanumab-dementia-drug-people-withalzheimersdisease#:~:text=aducanumab%20is%20an% 20antibody%20therapy 24. kumar, a., gupta, v., & sharma, s. (2022). donepezil. retrieved from pubmed website: https://www.ncbi.nlm.nih.gov/books/nbk5 13257/#:~:text=donepezil%20is%20fda% 20approved%20for 25. fang r, ye s, huangfu j, calimag dp. music therapy is a potential intervention for cognition of alzheimer's disease: a minireview. transl neurodegener. 2017 jan 25;6:2. doi: 10.1186/s40035-017-0073-9. pmid: 28149509; pmcid: pmc5267457. 26. alzheimer's association. (2015, december 31). prevention. alzheimer’s disease and dementia. https://www.alz.org/alzheimersdementia/research_progress/prevention 27. md, a. e. b. (2021, june 8). a new alzheimer’s drug has been approved. but should you take it? harvard health. https://www.health.harvard.edu/blog/a-newalzheimers-drug-has-been-approved-but-s hould-you-take-it202106082483#:~:text=aducanumab%20(br and%20name%20aduhelm)%20is https://www.alz.org/ https://www.alzheimers.org.uk/blog/what-is-aducanumab-dementia-drug-people-with-alzheimers-disease#:~:text=aducanumab%20is%20an%20antibody%20therapy https://www.alzheimers.org.uk/blog/what-is-aducanumab-dementia-drug-people-with-alzheimers-disease#:~:text=aducanumab%20is%20an%20antibody%20therapy https://www.alzheimers.org.uk/blog/what-is-aducanumab-dementia-drug-people-with-alzheimers-disease#:~:text=aducanumab%20is%20an%20antibody%20therapy https://www.alzheimers.org.uk/blog/what-is-aducanumab-dementia-drug-people-with-alzheimers-disease#:~:text=aducanumab%20is%20an%20antibody%20therapy https://www.alzheimers.org.uk/blog/what-is-aducanumab-dementia-drug-people-with-alzheimers-disease#:~:text=aducanumab%20is%20an%20antibody%20therapy https://www.ncbi.nlm.nih.gov/books/nbk513257/#:~:text=donepezil%20is%20fda%20approved%20for https://www.ncbi.nlm.nih.gov/books/nbk513257/#:~:text=donepezil%20is%20fda%20approved%20for https://www.ncbi.nlm.nih.gov/books/nbk513257/#:~:text=donepezil%20is%20fda%20approved%20for https://www.alz.org/alzheimers-dementia/research_progress/prevention https://www.alz.org/alzheimers-dementia/research_progress/prevention https://www.health.harvard.edu/blog/a-new-alzheimers-drug-has-been-appr https://www.health.harvard.edu/blog/a-new-alzheimers-drug-has-been-appr why is alzheimer’s disease more prevalent in the hispanic community? special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.76 dhr proceedings ǀ http://dhrproceedings.org 1 2023, vol. 2 no. s2 1-6 commentary epidemiology and other factors affecting weight loss in hispanics ivan espinoza1,2, anahi de leon1,2, daryl trejo1,2, lluvia villa1,2, luis salazar1,3, alondra martinez1,3, san juanita gonzalez1,3, melanie cruz1,3, orfelinda lopez1,3, angelica gonzalez1,3, xiomara rodriguez1,4, anahi ybarra1,4 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 robert vela high school, tx 3 donna north high school, tx 4 lasara high school, tx received: june 16, 2023 accepted for publication: october 25, 2023 published: november 16, 2023 introduction obesity in the hispanic population in the united states (us) is disproportionately higher when compared to that of other ethnicities (figure 1). at a rate of almost 50%, hispanics have higher rates of obesity than any other race or ethnicity in the us.1 factors contributing to obesity vary from genetics to the type of the food individuals consume. when looking at potential solutions and treatments for patients, the fundamental basis in obesity can include lifestyle changes. if this fails, medicine or surgery is most optimal for weight loss/recovery. figure 1. prevalence of obesity among adults aged 20 and over, by sex and age: united sates, 2015-2016 reference: https://www.cdc.gov/nchs/data/databriefs/db288.pdf factors contributing to weight gain genetic background and eating habits hispanics/latinos have a higher risk of obesity compared to other americans that may be related to their genetic background. with obesity on the rise worldwide, there is an urgent need to identify the factors that lead to weight gain and weight management. the united states, like other countries, has seen an increase in population sizes and hispanic/latinos racial diversity in recent decades. hispanic/latino adults and children/adolescents in the united states bear a greater burden of obesity than non-hispanic whites.2 some studies have suggested that genetic factors may play a role in the higher rates of obesity observed in the hispanic/latino population. for example, a study published in the journal plos genetics found that a specific genetic variant was associated with a higher body mass index (bmi) in hispanic/latino individuals.3 another study published in the international journal of obesity found that genetic variations in fat mass and obesity associated (fto) gene were more strongly associated with obesity in hispanic/latino populations than in nonhispanic white populations.4 however, it is important to note that genetic factors are just one piece of the puzzle when it comes to understanding obesity, and that lifestyle factors such as diet and physical activity also play a significant role. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.76 dhr proceedings ǀ http://dhrproceedings.org 2 2023, vol. 2 no. s2 1-6 eating habits and behaviors have been implicated in the clustering of obesity among socially connected people. for example, a study at the university of california san diego and connecticut incorporated adult latinas participating in a lifestyle intervention that completed an egocentric network measure of weight and weight control behaviors.5 this study determined how participants and their social ties are related and associated with weight change in participants. participants who reported more social ties and lost weight, were most likely to eat small portions and low-fat foods. participants who reported more social ties who exercised, drank liquid meal replacements, took herbal supplements, and selfweighted were more likely to lose weight. therefore, given that weight and weight control behavior of latinas reflects that of their social ties, targeting existing social networks for lifestyle interventions may more effectively improve and sustain health promoting behaviors and outcomes.6 many factors can contribute to excess weight gain including eating patterns, physical activity levels, and sleep routines. eating patterns emphasize a variety of vegetables and fruit, whole grains, a variety of lean foods, and low-fat and fat-free daily products. physical activity recommends that children aged three through five years should be physically active throughout the day. children aged 6-17 years need at least 60 minutes of moderate to vigorous physical activity every day. adults need 150 minutes of moderate intensity physical activity a week.7 mental health and activity levels there are factors that affect physical activity within the hispanic population. as we all know, physical activity is crucial for maintaining good health and preventing chronic diseases. however, there are several barriers that prevent hispanics from engaging in regular physical activity. many hispanics come from cultures where physical activity is not emphasized, and instead, they prioritize family and work. the diet of the hispanic culture is influenced by the parents of young adolescents.9,10 most of the foods hispanics consume contain large amounts of salt and sugar which can lead to atherosclerosis, plaque buildup in the heart, and glucose can turn into fat if not used during exercise. another factor that affects physical activity within the hispanic population is access to resources. the exclusion of hispanics pertains to the illegal immigration reform and immigrant responsibility act of 1996 many hispanics live in low-income neighborhoods where there are limited resources for physical activity, such as parks, gyms, or safe walking paths.8 this lack of access can make it challenging for them to engage in regular physical activity. in the hispanic adolescent population, 54.8% of girls tried to lose weight within the years of 2013 through 2016.7 boys of hispanic descent had a 8.2% difference from young women. overall, it is essential to understand the factors that affect physical activity within the hispanic population to create effective interventions that promote physical activity and improve health outcomes. the most prevalent health condition affecting the hispanic community is depression. emotional behaviors contribute to many people becoming depressed and because of this, it leads to the loss of appetite. ongoing stigma plays a huge role as to why many individuals do not seek the medical attention needed when they are stressed and overwhelmed which can also lead to weight loss. according to washburn, et.al., the hispanic population is severely affected by depression, a widespread psychiatric condition.11 many hispanics also have other medical conditions leading to the consumption of certain medications, which can lead to depression, and contribute to weight loss. the following two phrases include information, according to sadule-rios, numerous hispanics with depression who do not educate themselves or ask for medical advice sometimes may turn to illegal drugs which can also lead to the loss of appetite and weight loss.12 sadulerios also states that understanding depression and its causes can result in better evaluation procedures, early detection, and interventions, care, and services that are sensitive to cultural differences.12 complications or comorbid conditions obesity obesity has a major impact in the hispanic/ latino population. it starts by summing up the food they consume. obesity often builds up a disease in the body, which can result in a myocardial infarction, strokes or possible death. according to borlaugh, et al., obesity from the 1970’s into the 1980’s has increased from 15% to 40%. according to the study it has been estimated that 1 in 2 adults will be obese in the usa by 2023.14 although cardiovascular disease (cvd) is not often linked to the possibility of obesity, many other references besides this one have suggested that it is a major possibility. as one may know the human heart pumps blood at a certain rate, in this special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.76 dhr proceedings ǀ http://dhrproceedings.org 3 2023, vol. 2 no. s2 1-6 research it has been suggested that the increased need for energy due to obesity can be a great relation to why they are at such risk for cardiovascular disease. in the estimate, 40% to 50% of patients have diabetes and 15% to 25% are pre-diabetic.14 diabetes ethnic minority women tend to have a higher risk of exposure to diabetes, obesity and other illnesses. in type 2 diabetes, the pancreas makes less insulin than normal, and your body becomes resistant to insulin. something really common in type 2 diabetes is the way it affects hispanic women and minorities as a whole, and it’s involvement with obesity. diabetes tends to affect minority groups because of their health care, cultural behaviors and other determinants of health. research has shown that obesity plays a big role in the development of type 2 diabetes, being tied into about 98% of the cases.13 we as a whole have also been provided with research that proves 88% of adults with type 2 diabetes are considered obese.13 weight-loss methods lifestyle modifications exercise plays a crucial role in combating obesity among hispanics. regular physical activity offers numerous benefits that can contribute to weight management and overall health for hispanics. there are many reasons for obesity in the latino community and this may be due to the lack of knowledge about physical activity or access to other resources such as a workout program.15 hispanics should approach this by accompanying an exercise prescription describing frequency, intensity, type, and time with a minimum of 150 minutes moderate weekly activity.16 along with that, a high-quality diet should coexist to make the benefits substantial. research recommendations in recent us & uk guidelines typically advise increasing aerobic physical exercise, such as swift walking to reach a goal of 150 minutes per week or more. additionally, this is equal to 30 minutes a day, for at least 5 days each week. doing so benefits hispanic individuals for general health that are independent of weight loss. some evidence concludes that a greater amount of physical activity following 30 to 45 minutes per day is required to prevent obesity and for longterm weight maintenance for those who have lost weight, 60 to 90 minutes per day is essential.16 progressively, the next step is to get the right nutritional education and carefully monitor what is being consumed.15 there are several methods for dieting to lose weight. one method is by reducing calorie intake by 500 below regular requirements or by using a dietary plan which consists of 1200 to 1500 kcal/d for women or 1500 to 1800 kcal/d for men to accomplish this goal. the second method should be to burn more calories than the body consumes in a week or day. certain foods that are recommended for diets are: whole grains, vegetables, fruits, fish, nuts, and low-fat dairy products.17 correspondingly, there is an aiding factor that helps with the process and it is to include physical activity while dieting as it is an essential component to comprehensive lifestyle intervention for obesity management.15 reference: https://www.rwjbh.org/blog/2021/march/addressin g-diet-and-weight-issues-in-the-latino-/ medicinal therapies according to lu, et al. the semaglutide (ozempic) is an effective fda-approved drug for chronic weight management in adults with obesity or over-weight.18 however, there are concerns about its cost, access, and affordability, particularly in underserved and underrepresented communities, such as the hispanic community.18 in this study, researchers found that 57.1% of semaglutide-eligible adults who had attempted to lose weight in the past 12 months were hispanics.18 cohen, and gadde, researched other drugs that can help with weight loss therapy that have been approved in the united states are known as orlistat, lorcaserin, liraglutide, phentermine or topiramate, and naltrexone/bupropion.19 in addition, they stated that although considered a weight loss medication, naltrexone/bupropion results in an increase in in-office and ambulatory blood pressure compared to placebo.19 the most common medications used for weight loss are naltrexone and liraglutide although side effects are possible. the common side effects for naltrexone include nausea, constipation or diarrhea, insomnia and dry mouth. as for liraglutide, side effects include nausea, vomiting, diarrhea, constipation, headache, dizziness and low special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.76 dhr proceedings ǀ http://dhrproceedings.org 4 2023, vol. 2 no. s2 1-6 blood sugar in patients with diabetes. on the other hand, it is a good option to help in weight loss more in general with patients dealing with hypertension and obesity. the result of these medications are an intended result, safe, and effective. bariatric surgery bariatric surgery is a type of emaciating surgery that is used to rehabilitate obesity. according to centers for disease control and prevention (cdc), nearly 34% of the u.s. adult population is considered obese with a bmi of ≥ 30, while 6% of americans are considered extremely obese with a bmi > 40.20 in hispanic and black populations, the obesity rates are even higher than other ethnicities with 50% of blacks being obese while hispanics were closely behind with 39%.20 in order to combat obesity in the u.s. and amongst hispanics, many clinicians have recommended bariatric surgery as an alternative to common weight loss therapies. benaiges et al. (2015) states that bariatric surgery works by reducing the size of the stomach, which restrains the portion of food that can be consumed.21 additionally, the mayo clinic indicates that bariatric surgery is effective in maintaining long-term weight loss.21 bariatric surgery requires lifestyle changes and new acquired habits, which can lead to improved quality of life. the mayo clinic also indicates that aside from weight loss, improvements in blood pressure, heart disease, sleep apnea, diabetes, nonalcoholic fatty liver disease (nafld) or nonalcoholic steatohepatitis (nash), gastroesophageal reflux disease (gerd), and joint pain, can be observed.22 a study conducted by smith et. al., indicates disparities amongst latinos including, limited access to insurance coverage, low referral rates by primary doctor, cultural attitude towards obesity and distrust within the healthcare system reduces the access to bariatric surgery in these communities.23 conversely, edinburg consolidated independent school district, a local school district of the rio grande valley with a predominantly hispanic population, has tackled this issue head on with its coverage of bariatric surgery included in its health plan.24 thanks to this surgery, many hispanics are seeing and feeling rapid changes in their health and quality of life. the kaiser permanente electronic health records states that after three years, hispanic patients who got gastric bypass surgery lost 59% of their total weight.20 this means that patients who lost 59 percent of their excess weight lost an average of 81.5 pounds. bariatric surgeries can provide long-term weight loss. the amount of weight you lose depends on your type of surgery and your changes in lifestyle habits. it may be possible to lose half, or even more, of your excess weight within two years. conclusion although treatment plans can be beneficial for some, it is important to remember that genetic predispositions to obesity and diabetes play an important role in the development of these diseases. not all lifestyle modifications will work for everyone who is diagnosed with obesity, but there are openings for treatments such as medicinal therapies and surgery. listening to the patient and their feedback on why or how they are in their current position is necessary to individual’s treatment. blaming/shaming a patient will cause disdain for the health care community, which is not helpful. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. hales cm, carroll md, fryar cd, ogden cl. prevalence of obesity among adults and youth: united states, 2015-2016. nchs data brief. 2017 oct;(288):1-8. pmid: 29155689. 2. alemán jo, almandoz jp, frias jp, galindo rj. obesity among latinx people in the united states: a review. obesity (silver spring). 2023 feb;31(2):329-337. doi: 10.1002/oby.23638. pmid: 36695058; pmcid: pmc9937439. 3. chalazan, b., palm, d., sridhar, a., lee, c., argos, m., daviglus, m. l., rehman, j., konda, s., & darbar, d. (2021). common genetic variants associated with obesity in an african-american and hispanic/latino population. plos one, 16(5), e0250697. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.76 dhr proceedings ǀ http://dhrproceedings.org 5 2023, vol. 2 no. s2 1-6 4. mccaffery, j., papandonatos, g., huggins, g. et al. fto predicts weight regain in the look ahead clinical trial. int j obes 37, 1545–1552 (2013). 5. centers for disease control and prevention. causes of obesity. centers for disease control and prevention. published march 21, 2022. 6. marquez b, norman gj, fowler jh, gans km, marcus bh. weight and weight control behaviors of latinas and their social ties. health psychol. 2018 apr;37(4):318-325. doi: 10.1037/hea0000597. epub 2018 feb 1. pmid: 29389157; pmcid: pmc5880731. 7. attempts to lose weight among adolescents aged 16–19 in the united states, 2013–2016 | blogs | cdc. https://blogs.cdc.gov/nchs/2019/07/17/4552/ . published july 17, 2019 8. centers for disease control and prevention. (2022, june 27). unfair and unjust practices and conditions harm hispanic and latino people and drive health disparities. centers for disease control and prevention. https://www.cdc.gov/tobacco/healthequity/hispanic-latino/unfair-andunjust.html 9. feagin jr, cobas ja. latinos facing racism.; 2015. doi:10.4324/9781315633749 10. lindsay ac, wallington sf, lees fd, greaney ml. exploring how the home environment influences eating and physical activity habits of low-income, latino children of predominantly immigrant families: a qualitative study. international journal of environmental research and public health. 2018;15(5):978. doi:10.3390/ijerph15050978 11. washburn m, brewer k, gearing r, leal r, yu m, torres l. latinos' conceptualization of depression, diabetes, and mental healthrelated stigma. j racial ethn health disparities. 2022;9(5):1912-1922. doi:10.1007/s40615-021-01129-x 12. sadule-rios n. a review of the literature about depression in late life among hispanics in the united states. issues ment health nurs. 2012;33(7):458-468. doi:10.3109/01612840.2012.675415 13. williams js, lu k, akinboboye o, et al. trends in obesity and medical expenditure among women with diabetes, 2008-2016: differences by race/ethnicity. ethn dis. 2020;30(4):621-628. published 2020 sep 24. doi:10.18865/ed.30.4.621 14. borlaug ba, jensen md, kitzman dw, lam csp, obokata m, rider oj. obesity and heart failure with preserved ejection fraction: new insights and pathophysiological targets. cardiovasc res. 2023;118(18):3434-3450. doi:10.1093/cvr/cvac120 15. addressing diet and weight issues in the latino community. rwjbarnabas health. https://www.rwjbh.org/blog/2021/march/add ressing-diet-and-weight-issues-in-the-latino/. published march 24, 2021 16. bray, george a et al. “management of obesity.” lancet (london, england) vol. 387,10031 (2016): 1947-56. doi:10.1016/s0140-6736(16)00271-3 17. calorie deficit key to weight loss – here’s why. https://www.orlandohealth.com/contenthub/calorie-deficit-key-to-weight-loss-hereswhy#:~:text=to%20lose%20a%20pound%2 0of,of%201%2c000%20calories%20a%20d ay 18. lu y, liu y, krumholz hm. racial and ethnic disparities in financial barriers among overweight and obese adults eligible for semaglutide in the united states. j am heart assoc. 2022 oct 4;11(19):e025545. doi: 10.1161/jaha.121.025545. epub 2022 sep 29. erratum in: j am heart assoc. 2023 mar 21;12(6):e027630. pmid: 36172953; pmcid: pmc9673703. 19. cohen jb, gadde km. weight loss medications in the treatment of obesity and hypertension. curr hypertens rep. 2019 feb 12;21(2):16. doi: 10.1007/s11906-019-09151. pmid: 30747357; pmcid: pmc6415530. 20. medlin, d. d. (2019, february 21). for gastric bypass patients, percent of excess weight loss differs by race and ethnicity. kaiser permanente department of research & evaluation. https://www.kpscalresearch.org/for-gastric-bypass-patientspercent-of-excess-weight-loss-differs-byrace-andethnicity/#:~:text=they%20found%20%20t hat%2c%20on%20%20average,black%20p atients%20lost%2056%20percent. 21. benaiges, d., goday, a., pedro-botet, j., más, a., chillarón, j. j., & flores-le roux, j. a. (2015). bariatric surgery: to whom and when?. minerva endocrinologica, 40(2), 119–128. 22. bariatric surgery mayo clinic. (2023, october 18). https://www.mayoclinic.org/testshttps://www.mayoclinic.org/tests-procedures/bariatric-surgery/about/pac-20394258 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.76 dhr proceedings ǀ http://dhrproceedings.org 6 2023, vol. 2 no. s2 1-6 procedures/bariatric-surgery/about/pac20394258 23. smith, e. d., layden, b. t., hassan, c., & sanchez-johnsen, l. (2018). surgical treatment of obesity in latinos and african americans: future directions and recommendations to reduce disparities in bariatric surgery. bariatric surgical practice and patient care, 13(1), 2–11. https://doi.org/10.1089/bari.2017.0037 24. employee benefits department. (n.d.). https://www.ecisd.us/apps/pages/index.jsp?u rec_id=1311447&type=d&prec_id=157 5694 https://www.mayoclinic.org/tests-procedures/bariatric-surgery/about/pac-20394258 https://www.mayoclinic.org/tests-procedures/bariatric-surgery/about/pac-20394258 special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.63 dhr proceedings ǀ http://dhrproceedings.org 30 2022, vol. 2 no. s2 30-35 commentary overview of glioblastoma alvaro martinez1,2, cassandra maldonado1,2, galilea de leon1,2, jennifer agustin1,2, yolanda montelongo1,2, amber ramirez1,3, obed alvarez1,3, clarissa gomez1,4, alec kanhere1,4, marlina perez1,5 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2juarezlincoln high school, mission tx 3mcallen high school, mcallen tx 4roma high school, roma tx 5lyford high school, lyford tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/21/2022 accepted for publication 08/03/2022 published 08/03/2022 introduction glioblastoma multiforme (gbm), a rapidly developing and highly aggressive brain tumor, accounts for more than 49 percent of all primary malignant brain tumors (1). through the extensive research of medical professionals, the scientific community has gained a deeper understanding of gbm, and thus discovered common symptoms, medical treatments, and distinct therapies to attempt to treat the patient. treatment for gbm is challenging due to the disease's innate resistance to conventional therapy and its propensity for invasive behavior; as a result, more effective neuro-oncological and neurosurgical therapies are required (2). history discovery as one of the most complex brain tumors, it isn't a surprise that glioblastomas have a long line of history. although the origin of these brain tumors is unknown, records that indicate their existence date back to the 1800s. in 1800 and 1804, british scientific reports by burns and abernethy displayed the first ever recorded glioblastomas (3). in 1863, rudolf virchow, a german physician and founder of social medicine, provided the first comprehensive histomorphological description of this fast-growing malignant tumor (3). virchow was able to demonstrate the tumor's glial origin which ultimately created the steppingstone for future scientific researchers. researchers since the initial discovery of gbm, there have been plenty of researchers that continue to investigate the mystery of this deadly brain tumor. in 1914 american pathologist, frank burr mallory, was credited for coining the term glioblastoma multiforme. in 1926, researchers percival bailey and harvey cushing established the basis of modern classification from gliomas and glioblastomas, which they called gbm. scherer and kernohan were the most prolific researchers between the years of 1934 and 1941 and postulated some of the clinicmorphological aspects of glioblastomas (4). martinez, et al. overview of glioblastoma https://doi.org/10.47488/dhrp.v2is2.63 dhr proceedings ǀ http://dhrproceedings.org 31 2022, vol. 2 no. s2 30-35 glioblastoma formation glioblastoma is a cancerous tumor that develops in the brain. they form from astrocytes which are star-shaped cells that protect and provide nutrients to the brain. it’s common for glioblastoma to grow in the brainstem and cerebellum for most adults. these tumors can also metastasize in multiple areas of the brain, and in some rare cases it can even grow in other parts of the body (5). types of gbm glioblastoma has 2 types, primary glioblastoma and secondary glioblastoma. primary glioblastoma is more common for older people. it’s also the common type to have, and with this, your life expectancy will most likely be shortened. secondary glioblastoma mainly targets younger individuals. it forms from a low-grade glioma which can grow in almost any part of the brain and occasionally in the spinal cord. the survival rate for this type tends to be higher than the primary glioblastoma (5). similarities and differences like any kind of cancer found in the body, there are many differences and similarities between these malignant tumors. glioblastomas are a type of glioma, which is one of the most common types of brain tumors. with this classification it can be inferred that these tumors are quite similar. the only difference between the two is the severity of the tumor and grade. on the other hand, glioblastomas can be far more complex than other types of brain tumors and can show symptoms rather quickly. all brain tumors range from a grade scale between 1 and 4 (4 being the most dangerous and 1being the least dangerous). compared to the other brain cancers, all glioblastomas are considered grade iv brain tumors. the reason for this is that they have the most unusual looking cells ultimately making them the most aggressive (6). prognosis as of now the prognosis states that there is no possible cure for gbm. treatments are available for patients to keep the tumor in control for a couple of months, and if possible, even years. as glioblastoma continues to grow it creates microscopic branches that can spread to various parts of the brain, which can make it extremely difficult to remove through surgery. additionally, a single tumor contains different types of cells which can make it almost impossible to treat the whole tumor. for instance, if a drug is being used to treat the tumor, it will only kill a certain cell, not all of them (7). gbm prevalence rate of gbm glioblastoma multiforme (gbm) is the aggressive, most common brain tumor found in arising adults (8). every year, more than 13,000 american citizens are diagnosed with glioblastoma, and that’s not taking into consideration the amount of people who don’t participate in monthly checkups. glioblastoma has an already low survival rate of 40% within the first year. while things may look good in the beginning, chances decrease to 17% in just the second year, and to a 6.8% chance at the end of 5 years. this cancer has a terrifying population percentage, accounting for almost 50% of all brain cancer cases. in the united states on average there is a slightly higher rate in men than women affected by glioblastoma. with that caucasians compared to other ethnic groups such as african americans, asians, and american indians have a greater chance of diagnosis (9). gender distribution in the gender population, males have a faster exposure to the cancerous cell than females, due to their series of genetic alterations and exposure to growth factors (9). glioblastoma is more common in older males and begins around the age of 64. although it only begins at this age, it worsens and gets more fatal as the years pass. although gbm is found more frequently in men than women, recent studies have shown that females experience a higher intensity in symptoms and their tumors tend to be larger than those in males. the reason for these statistics is still unknown, but researchers are continuing to discover new information about these tumors. race/ ethnicity just like age and gender, a patient's race or ethnicity can be an additional factor that may give more information on survival and instances (10). in research studies based on race and ethnicities, it has been found that asians or pacific islanders have the highest 1year to 5-year survival rate (67.1%, 10.1%). african americans follow with a 1-year rate of 60.9% and a 5-year rate of 9.9%. hispanics are second to last with a rate of 60.4% in the first year and 9.5% in the martinez, et al. overview of glioblastoma https://doi.org/10.47488/dhrp.v2is2.63 dhr proceedings ǀ http://dhrproceedings.org 32 2022, vol. 2 no. s2 30-35 fifth year. lastly, nonhispanic whites have the lowest survival rate of 57.2% and 6.6% in the 1-to-5year period. although race and ethnicity are important to factor in a patient's diagnosis of gbm, there is still extensive research being done in this field for future data. causes & symptoms located either in the brain or spinal cord, this disease comes with many effects and critical symptoms including both psychiatric and neurological (8). neurological symptoms neurological symptoms are relatively shown during growth and expansion of the tumor. around 40 to 60 percent of patients with glioblastomas are prone to show neurological symptoms which include headaches, disorientation, vomiting, seizures, memory loss, and speech difficulties (8). the effect for this is due to the increased intracranial pressure in the frontal lobe and corpus callosum (8). the reason being, of these neurological symptoms are because of the amount of swelling due to the tumor and the desired room when growing (11). the tumor will push on the brain during a fast-spreading process that affects any nearby brain tissue (11). psychiatriatric symptoms most cases of glioblastoma show psychiatriatric symptoms and 62 percent of these cases are seen from middle aged to older patients (8). some primary psychiatriatric symptoms include depression, anxiety, manic-like states, and mood disorders (8). as much as 35% of patients manifest psychiatrist symptoms and are prone to be psychotic, have schizophrenia, resist treatment, and hallucinate (8). the reason for patients with gbm possessing these symptoms is due to tumors predominantly being pushed up against the temporal lobes ultimately affecting the frontal lobe (8). genetics the root cause for glioblastoma is unfortunately unknown and it has shown not to be inherited through genetics (12). although it is classified as an idiopathic tumor, some individuals with neurofibromatosis type 1, (a genetic cancer syndrome), turcot syndrome, and li fraumeni syndrome can elevate their chances for this disease (13). diagnosis due to glioblastoma being classified as a stage four cancer, it is one of the most aggressive and rapidly growing brain tumors (14). if a patient has gbm they will begin to feel symptoms such as headaches, speech, vision, hearing, thinking impairment, and more. a very common symptom in patients is losing vocabulary or forgetting thoughts easily. a way of finding glioblastomas is by taking an mri. when the patient feels these symptoms, they will have an mri taken to see whether there is a tumor in the first place and if they need surgery. in other cases, a surgical biopsy is needed to see if the mass detected is a glioblastoma or another type of brain tumor. for most patients, the median time it takes to receive a diagnosis is around 330 days; that is almost one full year (15). the time period for diagnosis does range between 156 to 776 days depending on how long it takes an individual to be tested. unfortunately, the reason it takes a long period of time for an individual to be diagnosed with gbm is because most patients don’t feel symptoms until 100 days after the tumor begins to develop. although early detection remains difficult, new technologies are being made to help identify early stages of glioblastoma. developments such as liquid biopsy and serum biomarker may allow for early diagnosis and early treatment in future cases of glioblastoma. treatment/therapy the typical course of treatment for a gbm entails surgery, daily radiation, and oral chemotherapy administered over the course of six and a half weeks, followed by a six-month oral chemotherapy regimen administered five days each month (16). currently, surgery to remove as much of the tumor as possible is the best course of action for glioblastoma, which is then followed by a chemotherapy and radiotherapy regimen. treatment history many hospitals and research teams have pursued the study of glioblastomas trying to better treat it and ultimately find a cure. although this certain tumor is very complex, many breakthrough discoveries have been made. in 1888, physician byrom bramwell was one of the first physicians to point out the surgical challenge that these tumors martinez, et al. overview of glioblastoma https://doi.org/10.47488/dhrp.v2is2.63 dhr proceedings ǀ http://dhrproceedings.org 33 2022, vol. 2 no. s2 30-35 brought to the table. he explained that without microscopical examination, it would be quite impossible to spot the transition between the tumorous tissue and normal brain tissue. furthermore, in our society today many institutes have partnered with universities around the country in hopes to advance medical care for patients who suffer from glioblastomas. the translational center of excellence (tce) in the abramson cancer center at penn medicine has focused on the issues of gbm and have continued to create opportunities to revolutionize treatment. the penn medicine team is an international leader in researching and treating glioblastoma and have made game-changing discoveries. they have ushered in a new era of cellular therapies that treat cancer with a patient’s immune system (17). in 2005, medical director at the lou and jean malnati brain tumor institute, roger stupp, developed a worldwide standard care for glioblastoma known as the stupp protocol. his findings in better treatment and new ways of treatment have changed the survival ratio of patients from 1 in 10 that lived longer than two years after diagnosis to now more than 1 in 4 (18). although there is still much to learn about glioblastomas, there have been great advancements in treatments. it is only a matter of time before scientific researchers find a cure. adjuvant therapy patients with glioblastoma begin chemotherapy 2 to 4 weeks following surgery. either along with radiation therapy or soon after it (19). gbms and other advanced brain tumors are frequently treated with temozolomide, a chemotherapeutic medication that the fda approved in 2013 (16). the medication slows the growth of tumors and is administered orally. usually, the medication is taken daily during radiation therapy and for six cycles after radiation during the maintenance phase (20). temozolomide not only has direct anticancer actions but also has immunomodulatory qualities (21). chemotherapy's effects are influenced by the drug's method of action, dosage, and host immune system (21). and then of course, there’s radiation. radiation therapy for glioblastoma involves directing x-rays, gamma rays, or photons at a tumor to kill malignant cells (22). the tumor shrinks as cancerous cells are cleared by the body's immune system, which relieves pressure on the brain. if a surgeon decides that removing a tumor would be too dangerous, it may be used as a primary treatment (16). it may also be performed following surgery to eliminate any cancerous cells that the surgeon was unable to see or reach. surgery for surgery, the neurosurgeon will attempt to remove the majority of the tumor (16). however, it is impossible to entirely eradicate gbms due to a zone of invading tumor cells that assault the tissues around the tumor. the neurosurgeon may also insert medicated wafers into the brain. over time, these wafers naturally break down and deliver chemotherapy medications into the tumor area (16). clinical trials all these wonderful treatments, but how effective are they? is the real question. well, the current standard of care for glioblastoma multiforme is successful and has extended survival times for more patients to two, three, and even four years. sadly, this treatment is not curative (16). which basically means that it does not terminate every single tumor cell. however, the outlooks and future for patients with glioblastoma are expected to improve. clinicians and researchers are developing new trials in an attempt to improve the survival rate of patients who have glioblastoma. a great example of this would be this fairly new clinical trial from a team at the university of michigan rogel cancer center. this certain clinical trial began in august of 2020 and is led by daniel wahl, m.d., ph.d. they hope to achieve and succeed where several other glioblastoma treatments have failed. this trial still has a very long way to go (23). in a brilliant ongoing clinical trial which is led by dr. andrew b. lassman, the john harris associate professor of neurology at columbia university vagelos college of physicians and surgeons and head of the neuro-oncology division at columbia university irving medical center/new york-presbyterian, observed tumor reduction in nearly a third of patients with recurrent glioblastoma, an aggressive brain cancer while using selinexor, the first of a new class of anticancer drugs. (24). these are only a few of the several ongoing clinical trials attempting to alter the course of glioblastoma patients' futures. mental health another important aspect that is very crucial to remember is that this patient is not only battling a martinez, et al. overview of glioblastoma https://doi.org/10.47488/dhrp.v2is2.63 dhr proceedings ǀ http://dhrproceedings.org 34 2022, vol. 2 no. s2 30-35 deadly unforgiving cancer, but they are also undergoing emotional distress such as anxiety and depression. any cancer really can have this effect. this is why it is crucial that you care for your patient and have some empathy. to assist patients in coping with the emotional distress and stress caused by cancer and its treatment, palliative care teams frequently include social workers and/or other mental health specialists. to improve the general quality of life for cancer patients, therapists and counselors can provide their services in person or online (25). conclusion despite improvements in our understanding of gbm, its inherent invasiveness and resistance to standard treatments makes it extremely difficult to find a cure. it is important to educate healthcare and local communities on the importance of the severity of glioblastomas to inculcate the urgency in patients to seek medical attention once neurological symptoms are detected. in doing so, the patient’s overall physical and emotional well-being may be exceptionally improved. as experts continue to advance their medical care for those suffering from gbm, exposing its severity to local communities yields the patient a better prognosis. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. about gbm gbm awareness day. (n.d.). national brain tumor society. https://braintumor.org/take-action/aboutgbm/?gclid=cjwkcajw2rmwbhb4eiwaij 0mtfrjyizykxsetulau upfcjteneouivmqflgfk2jyauief1vp2vzbocw30qavd_bwe 2. american association of neurological surgeons. (2019). glioblastoma multiforme symptoms, diagnosis and treatment options. aans.org. https://www.aans.org/en/patients/neurosurgi cal-conditions-andtreatments/glioblastoma-multiforme 3. stoyanov, g. s., & dzhenkov, d. l. (2018). on the concepts and history of glioblastoma multiforme morphology, genetics and epigenetics. folia medica, 60(1), 48–66. https://doi.org/10.1515/folmed-2017-0069 4. iacob, g., & dinca, e. b. (2009). current data and strategy in glioblastoma multiforme. journal of medicine and life, 2(4), 386–393. 5. peri, c. (2014, may 12). what is glioblastoma? webmd; webmd. https://www.webmd.com/cancer/braincancer/what-is-glioblastoma 6. suter, r. k., rodriguez-blanco, j., & ayad, n. g. (2020). epigenetic pathways and plasticity in brain tumors. neurobiology of disease, 145, 105060. https://doi.org/10.1016/j.nbd.2020.105060 7. glioblastoma. (2016). md anderson cancer center. https://www.mdanderson.org/cancertypes/glioblastoma.html 8. leo, r. j., frodey, j. n., & ruggieri, m. l. (2020). subtle neuropsychiatric symptoms of glioblastoma multiforme misdiagnosed as depression. bmj case reports, 13(3), e233208. https://doi.org/10.1136/bcr-2019233208 9. carrano, a., juarez, j. j., incontri, d., ibarra, a., & guerrero cazares, h. (2021). sexspecific differences in glioblastoma. cells, 10(7), 1783. https://doi.org/10.3390/cells10071783 10. patel, n. p., lyon, k. a., & huang, j. h. (2019). the effect of race on the prognosis of the glioblastoma patient: a brief review. neurological research, 41(11), 967–971. https://doi.org/10.1080/01616412.2019.1638 018 11. roberts, s. (n.d.). glioblastoma. nord (national organization for rare disorders). retrieved july 18, 2022, from https://rarediseases.org/gard-raredisease/glioblastoma/ 12. glioblastoma: symptoms, causes, treatment & prognosis. (n.d.). cleveland clinic. https://my.clevelandclinic.org/health/disease s/17032-glioblastoma 13. glioblastoma | genetic and rare diseases information center (gard) – an ncats https://www.aans.org/en/patients/neurosurgical-conditions-and-treatments/glioblastoma-multiforme https://www.aans.org/en/patients/neurosurgical-conditions-and-treatments/glioblastoma-multiforme https://www.aans.org/en/patients/neurosurgical-conditions-and-treatments/glioblastoma-multiforme martinez, et al. overview of glioblastoma https://doi.org/10.47488/dhrp.v2is2.63 dhr proceedings ǀ http://dhrproceedings.org 35 2022, vol. 2 no. s2 30-35 program. (2015). nih.gov. https://rarediseases.info.nih.gov/diseases/24 91/glioblastoma 14. what is glioblastoma? symptoms, causes, diagnosis, treatment, and prevention. (n.d.). everydayhealth.com. https://www.everydayhealth.com/cancer/brai n-tumor/glioblastoma-signs-symptomslatest-treatmentsmore/#:~:text=signs%20and%20symptoms %20of%20glioblastoma 15. why glioblastoma tumors like john mccain’s are so aggressive. (2017, july 20). pbs newshour. https://www.pbs.org/newshour/science/gliob lastoma-tumors-like-john-mccainsaggressive 16. weingart, j. (2021, october 12). glioblastoma multiforme (gbm): advancing treatment for a dangerous brain tumor. johns hopkins medicine. retrieved july 17, 2022, from https://www.hopkinsmedicine.org/health/co nditions-and-diseases/glioblastomamultiforme-gbm-advancing -treatment-for-adangerous-brain-tumor 17. weller, m., butowski, n., tran, d. d., recht, l. d., lim, m., hirte, h., ashby, l., mechtler, l., goldlust, s. a., iwamoto, f., drappatz, j., o'rourke, d. m., wong, m., hamilton, m. g., finocchiaro, g., perry, j., wick, w., green, j., he, y., turner, c. d., … act iv trial investigators (2017). rindopepimut with temozolomide for patients with newly diagnosed, egfrviiiexpressing glioblastoma (act iv): a randomized, double-blind, international phase 3 trial. the lancet. oncology, 18(10), 1373–1385. https://doi.org/10.1016/s14702045(17)30517-x 18. stupp, r., mason, w. p., van den bent, m. j., weller, m., fisher, b., taphoorn, m. j., belanger, k., brandes, a. a., marosi, c., bogdahn, u., curschmann, j., janzer, r. c., ludwin, s. k., gorlia, t., allgeier, a., lacombe, d., cairncross, j. g., eisenhauer, e., mirimanoff, r. o., european organisation for research and treatment of cancer brain tumor and radiotherapy groups, … national cancer institute of canada clinical trials group (2005). radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. the new england journal of medicine, 352(10), 987– 996. https://doi.org/10.1056/nejmoa043330 19. cancer center, m. o. f. f. i. t. t. (n.d.). glioblastoma chemotherapy. moffitt cancer center. retrieved july 17, 2022, from https://moffitt.org/cancers/glioblastoma/treat ment/chemotherapy/ 20. prabhu, v. (n.d.). glioblastoma multiforme. aans. retrieved july 17, 2022, from https://www.aans.org/en/patients/neurosurgi cal-conditions-andtreatments/glioblastoma-multiforme#:~:t ext=chemotherapy%20with%20the%20dru g%20temozolomide, radiation%20during%20the%20maintenan ce%20phase. 21. karachi, a., dastmalchi, f., mitchell, d. a., & rahman, m. (2018). temozolomide for immunomodulation in the treatment of glioblastoma. neuro-oncology, 20(12), 1566–1572. https://doi.org/10.1093/neuonc/noy072 22. glioblastoma radiation. (n.d.). moffitt cancer center. https://moffitt.org/cancers/glioblastoma/treat ment/radiation/ 23. megdell, a. (2022, march 10). for glioblastoma, a new clinical trial fosters innovation and hope. university of michigan. retrieved july 17, 2022, from https://labblog.uofmhealth.org/labreport/for-glioblastoma-a-new-clinical-trialfosters-innovation-and-hope 24. university, c. (2022, february 4). promising treatment for deadly brain cancer. herbert irving comprehensive cancer center (hiccc) new york. retrieved july 19, 2022, from https://www.cancer.columbia.edu/news/pro mising-treatment-deadly-brain-cancer 25. peterson, t. (2020, october 22). how people with cancer can benefit from online therapy. cancer.net. retrieved july 17, 2022, from https://www.cancer.net/blog/2020-10/howpeople-with-cancer-can-benefit-onlinetherapy#:~:text=palliativ e%20care%20 teams%20often%20 include, life%20for%20people%20with%20cancer https://moffitt.org/cancers/glioblastoma/treatment/radiation/ https://moffitt.org/cancers/glioblastoma/treatment/radiation/ special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.85 dhr proceedings ǀ http://dhrproceedings.org 24 2023, vol. 2 no. s2 24-27 commentary psychosomatic disorder in women with exposure to violence or stress abigail alejandro1,2 grecia benavidez1,2 ailee cruz11,3 juan garcia1,4 mia garza1,4 victoria garza1,4 catherin guerra1,4 christin hernandez1,3 fatima montes1,4 jocelyn olvera1,3 lanika reyna1,4 graciela vela1,4 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 los fresnos high school 3 pharr-san juan-alamo independent school district 4 la grulla high school received: june 29, 2023 accepted for publication: august 25, 2023 published: november 15, 2023 introduction have you ever had a weird symptom and immediately jumped to conclusions about a severe illness you might have? maybe you had a bug bite near your armpit and thought it was cancer. or perhaps, during the pandemic, swore you had symptoms of covid-19 if there was an encountered or exposure to someone that had contracted the virus. these constant, abnormal, thoughts are one of the many factors of a mental illness defined as psychosomatic disorder. psychosomatic disorder is one of the most difficult disorders to diagnose in patients because it is often associated without any medical explanation. it is most common in women who have gone through trauma, stress, abuse, or violence.1 psychosomatic disorder is a psychological state characterized by the manifestation of physical symptoms in a person that is difficult to be medically explained and diagnosed.2 a person with psychosomatic disorder may overthink and cause these anomalies to become far worse than they are. people may dwell on the symptoms of an illness and eventually make themselves feel or become sick. although anyone may experience psychosomatic disorder at any point in their lives, it is more probable in women who have undergone a violent act, addiction, neglect, loss, abuse, or any traumatic event such as covid-19.3 definition what exactly is psychosomatic disorder? the word psycho is associated with mental disorders and somatic is related to conditions of the body.2 therefore, psychosomatic disorder, in scientific definition, is a condition where the patient believes they are suffering from a medical condition; however, there is no clear medical cause.2 consequently, patients gain plenty of anxiety and paranoia stuck on the thought that there could be an underlying medical issue they are experiencing. this can lead to many emotions such as frustration and fear. eventually, physical and mental factors take a strenuous toll on women with the disorder, and it manifests through many symptoms. fatigue, insomnia, aches/pains throughout the body, hypertension, trouble breathing, ulcers, indigestion, and headaches are some of the deteriorating symptoms accompanied by the disorder.2 these physical symptoms add to the distress, feeding into the belief that something is wrong with them. in regards to its history, it was originally waved as hysteria. therefore, the discovery and diagnosis of psychosomatic disorder was delayed. even now, women are portrayed as “dramatic” and “fragile”.3 currently, scientists and doctors still have not come up with a conclusion as to why it occurs. people struggle physically due to stress, hormones, and chemical build-up. women, especially those who special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.85 dhr proceedings ǀ http://dhrproceedings.org 25 2023, vol. 2 no. s2 24-27 have experienced violence or abuse, are significantly more prone to being diagnosed with psychosomatic disorder.3 symptoms psychological symptoms women who have a history of previous mental or physical abuse are more susceptible to experiencing terminal effects on their health.4 over a period of three years, women who were older, black, and/or divorced appeared to become more vulnerable than others in experiencing psychosomatic disorder symptoms.4 some examples of the mental symptoms the disorder causes are hallucinations, paranoia, anxiety, depression, and suicidal tendencies.4 in the years 1968 through 1980, adults 30 to 80 years old were given a self-administered questionnaire asking about their prevalence of psychosomatic symptoms.4 many of the symptoms were physical, but the majority were stress-related mental health issues. patients also indicated a sense of frustration by the lack of proper diagnosing procedures.4 many women are not believed or heard when they speak out on the existing symptoms they have been experiencing, so they become ill and depressed. the experience they had with health professionals along with the pre-existing anxiety and paranoia can lead a patient to suicidal and life-threatening situations. physical symptoms as mentioned earlier, there are many symptoms that come with psychosomatic disorder, most of which are psychological. however, some physical symptoms can cause discomfort to a patient. female patients with psychosomatic disorders tend to experience very high levels of stress. thus, they undergo physical effects such as abdominal symptoms (constipation, diarrhea, or other abdominal pain), headache/migraine, hypertension, fatigue, insomnia, and musculoskeletal symptoms; all of which deteriorate a patient's health status.4 many of these physical effects can progress into more serious underlying disorders such as personality disorders.2 mental disorders can greatly impact physical health and can contribute to the progression of psychosomatic disorders and deterioration of overall health. mental health effects on women women are more predisposed to developing stress-related disorders such as anxiety and depression. findings from the 2020 health survey of catalonia demonstrate that the percentage of women with psychosomatic disorders was 24.2% higher than men.5 further studies determined that the increase in prevalence in women may be correlated to higher rates of women who experience physical, emotional, and/or sexual abuse, hindering their mental health. the violence against women results in the vulnerability of women’s mental and physical health leading to possible trauma-related psychosomatic symptoms.6 women who have experienced physical and sexual abuse may develop ptsd, depression, anxiety, and other linked disorders. with the torment on their mental state, women begin to face psychosocial effects that contribute to somatic symptoms. the mental health of women is determined by the expression of psychosomatic symptoms based on self-questionnaires that ask for a specific set of symptoms. however, correlating symptoms such as anxiety, depression, and mood swings to somatic symptoms can result in the manipulation of a woman’s understanding of her own health. when reliving psychological trauma, women show an increase in psychosomatic symptoms such as lack of sleep, depressive periods, anxiety and trauma-related anxiety.2 the repression of thoughts and emotions actually increases somatic symptoms and the deterioration of physical health. moreover, women can also experience fear when revealing the traumatic events due to women being stigmatized as “dramatic” or too “sensitive”.7 therefore, women with psychosomatic disorders tend to be overlooked, causing symptoms to progress without treatment. such frustrations develop further stress on the psychological aspect of the psychosomatic disorder, creating a cycle of worsening symptoms.8 causes and prevention causes although there are no particular causes of the disorder, several factors can contribute to it.4 for example, substance abuse, violence, anxiety, and depression can all be factors that eventually trigger psychosomatic disorders.4 women who have high stress levels and are constantly in a state of panic are more susceptible to the disorder. additionally, smoking and substance abuse are some of the many detrimental ways that women try to relieve the stress special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.85 dhr proceedings ǀ http://dhrproceedings.org 26 2023, vol. 2 no. s2 24-27 of psychosomatic disorder.4 this can trigger even more symptoms of the disorder. prevention if a patient exhibits early indicators of the disorder or any of the contributing factors, it is important to be self-aware. having an open mind to possibilities and being accepting of an issue can prevent a world of problems. getting regular checkups with doctors is a vital part of preventing and treating the disorder. seeking aid such as therapy for previous trauma can be an effective way of preventing symptoms and even contraction of the disorder. specialists since patients with psychosomatic disorders have so many concerns about their health, it is hard to pinpoint just one specialist they consult with. physicians, therapists, and general doctors are some of the examples of specialists they visit often. however, psychiatrists, specifically liaison psychiatrists, are medical doctors who specialize in diagnosing, treating, and caring for patients with psychosomatic disorders.9 liaison psychiatry is a sub-specialty that specifies the physical and psychological components of a patient.9 it takes a lot of hard work and dedication to be successful in this profession, so it is clear that these doctors are well educated and equipped to treat patients with the disorder. their role in psychosomatic illness consists of therapeutic and emergency services to suicidal patients as well as the prevention of symptoms for patients.10 a multidisciplinary approach with a variety of specialists is crucial in the diagnosis of psychosomatic disorder in women who have experienced trauma, violence, and abuse.3 treatment according to a study, the most effective treatment for psychosomatic disorder is well-being therapy, which is a psychotherapeutic strategy that emphasizes self-observation. it helps patients to improve their interpersonal relationships and to be able to observe the symptoms they present in therapy.11 people suffering from psychosomatic disorder should be diagnosed by their primary care physician first, and then later referred to a psychiatrist for treatment. age, competence, duration of the disorder, and the type of personality that the patient possesses must be taken into account when determining the treatment plan for the patient. the psychiatric treatments for a patient with psychosomatic illness may include 8 weeks of regular electroconvulsive therapy sessions, to help quickly reverse symptoms of the disorder.11 some other psychiatric treatments include psychopharmacological treatments, such as antidepressants, which are most appropriate since they are the most common for this type of disorder.11 treatment options can also include hypnosis to stimulate the subject to find her own subconscious healing resources. furthermore, pharmacological abreaction, which involves interviewing individuals under the influence of a drug to elicit repressed emotions or traumatic experiences or to discover unconscious thoughts and feelings, can help a patient achieve emotional catharsis. group therapy is also an option that helps the patients to learn, practice recovery strategies, and build interpersonal skills. additionally, supportive psychotherapy administered by a psychiatrist helps to restore a person's relationship to social norms and regulations, while psychoanalysis works to strengthen the patient's relationship to their own subconscious mind.12 each of these are available treatments that can assist women in achieving relief from psychosomatic disorder. conclusion psychosomatic disorder is harmful to a women's mental and physical health. women who have experienced trauma and violence are more prone to suffer from this disorder. patients can be left frustrated, with an unanswered question, as to why they are experiencing physical symptoms, while medical providers have difficulty identifying a medical explanation or diagnosis for their symptoms. through physical afflictions varying from fatigue or infections to bruises and deleterious mental issues such as anxiety or depression, psychosomatic disorder is an illness that sends individuals downwards in a continuous cycle that they cannot comprehend. it is imperative to understand the spectrum of symptoms that can be associated with psychosomatic disorder as well as the reasons behind its development, including abuse and violence. ultimately, what is a life-altering disorder that commonly appears self-inflicted, in reality, encompasses detrimental psychological obstacles that must be overcome to in order to bring resolution to the somatic ailments. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.85 dhr proceedings ǀ http://dhrproceedings.org 27 2023, vol. 2 no. s2 24-27 acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. sweeting hn, west pb, der gj. explanations for female excess psychosomatic symptoms in adolescence: evidence from a school-based cohort in the west of scotland. bmc public health. 2007 oct 22;7:298. doi: 10.1186/1471-2458-7298. pmid: 17953744; pmcid: pmc2233615. 2. cleveland clinic. “psychosomatic disorder: what is it, symptoms, diagnosis & treatment.” cleveland clinic, 30 apr. 2021, my.clevelandclinic.org/health/diseases/2152 1-psychosomatic-disorder. 3. dillon g, hussain r, loxton d, rahman s. mental and physical health and intimate partner violence against women: a review of the literature. int j family med. 2013;2013:313909. doi:10.1155/2013/313909 4. hange d, mehlig k, lissner l, et al. perceived mental stress in women associated with psychosomatic symptoms, but not mortality: observations from the population study of women in gothenburg, sweden. int j gen med. 2013;6:307-315. published 2013 apr 24. doi:10.2147/ijgm.s42201 5. torrubia-pérez e, reverté-villarroya s, fernández-sáez j, martorell-poveda ma. analysis of psychosomatic disorders according to age and sex in a rural area: a population-based study. j pers med. 2022;12(10):1730. published 2022 oct 18. doi:10.3390/jpm12101730 6. harbishettar v, math sb. violence against women in india: comprehensive care for survivors. indian j med res. 2014;140(2):157-159. 7. plevkova j, brozmanova m, harsanyiova j, sterusky m, honetschlager j, buday t. various aspects of sex and gender bias in biomedical research. physiol res. 2020;69(suppl 3):s367-s378. doi:10.33549/physiolres.934593 8. sadock b, sadock v, ruiz p. kaplan and sadock’s synopsis of psychiatry behavioural sciences/clinical psychiatry. 11th ed. philadelphia (pa): wolters kluwer; 2015. 9. gautam s, gautam m, jain a, yadav k. overview of practice of consultation-liaison psychiatry. indian j psychiatry. 2022;64(suppl 2):s201-s210. doi:10.4103/indianjpsychiatry.indianjpsychi atry_1019_21 10. thomas, dr. l. (2022, december 26). what is psychosomatic medicine?. news. https://www.news-medical.net/health/whatis-psychosomatic-medicine.aspx 11. wittkower ed. treatment of psychosomatic disorders. can med assoc j. 1964;90(18):1055-1060. 12. parth k, rosar a, stastka k, storck t, löffler-stastka h. psychosomatic patients in integrated care: which treatment mediators do we have to focus on? bull menninger clin. 2016;80(4):326347.doi:10.1521/bumc.2016.80.4.326 13. šitum m, kolić m, buljan m. acta med croatica. 2016;70 suppl 1:35-38. special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.62 dhr proceedings ǀ http://dhrproceedings.org 23 2022, vol. 2 no. s2 23-29 commentary pediatric acute lymphocytic leukemia paris canales1,2, ashley contreras1,2, gerald esguerra1,2, raul garcia1,3, kimberly garza1,3, matthew gonzalez1,2, danika lopez-torres1,3, edith paez1,3, nolan salinas1,3, kayra sernaherrera1,3 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2 nikki rowe high school, mcallen tx 3 edinburg north high school, edinburg tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/21/2022 accepted for publication 08/03/2022 published 08/03/2022 introduction leukemia is a type of cancer that most commonly affects the bone marrow and other blood forming organs to produce an increased number of blastic leukocytes. additionally, leukemia isn’t just a cancer that affects the white blood cells, it also affects the erythrocytes. the effect that leukemia has on the erythrocytes could also cause various types of anemia. moreover, leukemia is responsible for 1 out of 3 cancers found in the pediatric group [1]. but in the years 2013-2017, leukemia and lymphoma accounted for nearly 40% of all cancers found in people less than 20 years old [2]. types of leukemia furthermore, there are different types of leukemia and are categorized as chronic (slow) or acute (fast). digging deeper into the types of leukemias, there are 2 major types of variants, lymphocytic and myelogenous [3]. myelogenous leukemia is a type of leukemia that starts in the bone marrow while lymphocytic leukemia starts in the white blood cells (leucocytes). these 2 types also come in a chronic and acute form. there are also more rare types of leukemias like hairy cell leukemia, myelodysplastic syndromes, and myeloproliferative disorders [4]. acute lymphocytic leukemia the most common of these leukemias in children is acute lymphocytic leukemia (all). approximately, 75% of all leukemia cases around the world are diagnosed in children residing in the united states [3]. symptoms acute lymphocytic leukemia being an extremely rare and fast paced disease. many times, children diagnosed with acute lymphocytic leukemia experience little to no symptoms within the months, weeks, and even days before being diagnosed due to the white blood cells in the blood expanding at a rapid rate [5]. the most common or first symptom is extreme fatigue. many patients cannot move for the reason that when their blood count is checked, their red blood cell count canales, et al. pediatric acute lymphocytic leukemia https://doi.org/10.47488/dhrp.v2is2.62 dhr proceedings ǀ http://dhrproceedings.org 24 2022, vol. 2 no. s2 23-29 is drastically low, and they are not getting enough oxygen. developing pneumonia is also really common. antibiotics do not work after developing pneumonia because the immune system is really low [5]. symptoms of acute lymphocytic leukemia are the following: ● anemia occurs when red blood cells are not produced due to the center of the bones overflowing with leukemic cells. ● bleeding and/or bruising happens when the bone marrow does not manufacture sufficient platelets also known as megakaryocytes. ● bone and joint pain can occur due to the bone marrow being overfilled with leukemic blasts. ● recurrent fevers/infections may demonstrate elevated quantities of white blood cells that are immature and do not fight infection. ● abdominal pain happens when leukemic cells gather in the kidneys, liver, and spleen occasioning the expansion of the organs. ● swollen lymph nodes can occur when leukemia cells gather in the lymph nodes causing them to swell. ● difficulty breathing happens when cells build up together in the thymus and underneath the breastbone surrounding the throat [6]. diagnosis the identification of a disease is known as a diagnosis. there are two tests that can accurately diagnose acute lymphocytic leukemia in children and determine the severity of the disease: blood testing and bone marrow tests [7]. a blood sample must be taken before a blood test may start. since pediatric oncologists work with children, a lancet, a device that pricks a finger to draw blood from the capillary vein found there, must be used to take a sample of their blood [7]. once pediatric oncologists collect their blood samples and send them to a lab, a complete blood count and blood smear will be performed to determine if the kids have leukemia and make a diagnosis. a complete blood count is a numerical result of how many blood cells are in a patient’s blood [7]. an abnormal blood cell count in children is a critical indicator for any pediatric oncologist to begin to suspect leukemia. a blood smear is a droplet of blood that is put on a glass slide and examined under a microscope [7]. a closer examination of a pediatric patient’s blood may further bring a pediatric oncologist to make a diagnosis because a change in the appearance of these cells may lead them to suspect all. a pediatric oncologist's concerns may be raised by an unusual blood cell count and a change in the appearance of a child's blood cells, but all cannot be definitively identified without analyzing a sample of the child's bone marrow cells. bone marrow is a semi-solid tissue found within the spongy, also known as cancellous, portions of bones. the spongy tissue can be found within a person’s hip and thigh bones. there are two bone marrow sample collection methods that can be utilized: bone marrow aspiration and biopsy. both of these procedures are typically carried out simultaneously, but both are necessary for testing all. a little amount of liquid bone marrow is aspirated using a syringe after a thin, hollow needle is introduced into the bone to perform a bone marrow aspiration [7]. the aspiration is then typically followed by a bone marrow biopsy. a slightly larger needle that is inserted down into the bone to remove a little bit of bone and marrow [7]. pressure will be provided to the area once the biopsy is completed to aid in stopping any bleeding. stages of progression usually, the progression or stages of cancers are categorized by stage i, ii, iii, or iv. this is determined by how far away the cancer cells moved from where it originally began. for example, in breast cancer, if the tumor is located only in the breast, this would mean the cancer is in stage i. if the cancer cells travel into the brain or the liver, it would be identified as stage iv [8]. in the case of leukemia, the blood cells themselves are the malignant cells. the production of blood cells goes out of control causing the cancer to spread throughout your body. these new cells that are produced are abnormal and won’t efficiently function as they were meant to do. healthy cells will be caught by the crossfire causing buildup and crowds will start to form [9]. at the time of a diagnosis, leukemia cells are present in the blood and in the bone marrow. using this information, it is either an active disease or it’s in remission [8]. dna mutations and genetics acute lymphocytic leukemia (all) is the most common cancer found in pediatrics. while there is no found direct cause of this disease it has been linked mainly to both genetic alterations and a phenomenon of dna mutations. all arises from the malignant transformation of progenitor band t-cells in the bone marrow into leukemic cells. genes that help keep cell division under control or cause cells to die at the right time are called tumor suppressor genes. a translocation seen in mostly all cases of childhood https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/malignant-transformation https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/malignant-transformation canales, et al. pediatric acute lymphocytic leukemia https://doi.org/10.47488/dhrp.v2is2.62 dhr proceedings ǀ http://dhrproceedings.org 25 2022, vol. 2 no. s2 23-29 all is the swap between chromosomes 9 and 22 also known as the philadelphia chromosome [3]. the swap between the chromosomes causes the oncogenes to help the leukemic cells grow within the body. intensive treatment due to a poor prognosis illustrates that there is a complex intrachromosomal amplification of chromosome 21 that is most common to pediatric all patients. secondary deletions or mutations may cause alterations in lymphoid transcription factors, cell cycle regulations, and tumor suppression [10]. studies have indicated that many all mutations are present at low variant allele frequency and therefore become subclonal [11]. in acute lymphocytic leukemia, hyperdiploidy is defined as the non-random gain of chromosomes, increasing the modal chromosome number of leukemic blasts from 46 to between 51 and 65 or 67. leukemic cells experiencing near or low hypodiploid tend to undergo a process that causes the hyperdiploid clone to double causing the drastic increase in number of chromosomes found in all patients predominantly in children [12]. the increase of hyperdiploid clones leads to what is called masked hyperdiploidy which is found in 60-65% of all patients, 25-30% being children [13]. masked hyperdiploidy is clinically challenging for patients battling with all and serves as one of many dna abnormalities contained in this disease. in addition, genetics has led to some of the world’s most underlying diseases and disorders. inherited genes play a key role in the growth and or demise of leukemic cells in pediatric all patients. several genetic conditions have taken a severe part in the development of acute lymphocytic leukemia, these conditions include but not limited to down syndrome, neurofibromatosis type 1, bloom syndrome, fanconi anemia, ataxia-telangiectasia, and li-fraumeni syndrome [14]. although these conditions can contribute to all, down syndrome has played the predominant contribution to this disease. down syndrome is defined as a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. down syndrome affects 1 in every 700 infants which allows for an increased risk of developing leukemia. since children with down syndrome have an extra copy of chromosome 21 they are more likely to have faulty genes; these children are 33 times more likely to develop all [15]. children with down syndrome not only have an increased risk of developing all, but they have an increased 2.1% cumulative risk of developing the disease before the age of 5 [14]. treatment options chemotherapy chemotherapy is one of the main treatments for cancerous patients. this treatment is used to reduce the number of cancer cells in the body. although very helpful, chemotherapy can decrease health through the removal of healthy cells. depending on the patient, they are capable of feeling fatigue, hair loss, and having several infections [16]. chemotherapy can differ depending on a patient's health status and the type of cancer they are experiencing. radiation therapy radiation therapy is a form of treatment that focuses on the removal of cancerous cells. this therapy can be a very laborious process, so it requires a lot of patience. radiation therapy can be very similar to chemotherapy in the fact that it requires an immense number of time. external radiation therapy is a form of treatment associated with radiation therapy. this treatment heals places where acute leukemia has expanded in a child's system [14]. chemotherapy with stem cell transplant chemotherapy with stem cell transplant is similar to chemotherapy, but it is not the primary treatment for children. children aren’t able to take large doses of chemotherapy because of their development [17]. with stem cell transplant, children are able to have a greater outcome. this means that children are able to have a higher intake of chemotherapy. targeted therapy targeted therapies are forms of treatments that specifically target a certain type of cancer cells, while avoiding healthy tissues [14]. this is a preferred treatment route due to the fact that standard treatments like chemotherapy and radiation therapy destroy normal, non-cancer cells. this is partially counterintuitive because in killing healthy cells, the body loses important stationary cells that continue growth. tyrosine kinase inhibitor (tkis) therapy this form of treatment is specific to blocking the enzyme, tyrosine kinase, that causes an overproduction of white blood cells within the body. three of the most common tki medications are: imatinib mesylate, dasatinib, and ruxolitinib. these three drugs canales, et al. pediatric acute lymphocytic leukemia https://doi.org/10.47488/dhrp.v2is2.62 dhr proceedings ǀ http://dhrproceedings.org 26 2022, vol. 2 no. s2 23-29 are used in several other cancers and conditions; they can help stop the growth of cancerous cells and may even help in killing malignant cells [14]. monoclonal antibodies moving on, monoclonal antibodies are laboratory-developed proteins that help fight specific diseases, such as cancer. this type of treatment is usually thought of as an option for patients with acute lymphocytic leukemia that doesn’t respond to other common treatments. one monoclonal antibiotic infusion being studied and used in pediatrics is blinatumomab. blinatumomab is more specifically used to treat b-cell all that is in remission, has recently come back, or when an all patient doesn’t respond to other treatment options [14]. immunotherapy immunotherapy is an innovative type of treatment that focuses on assisting the body in its own natural defense mechanisms. this form of therapy effectively utilizes the substances created by the body or those made in a laboratory to direct more attention to a given disease, in this case, acute lymphocytic leukemia [14]. car t-cell therapy this form of treatment is a procedure in which some t cells are removed from the patient and given a special receptor. the new cells are known as chimeric antigen receptor (car) t cells. the car t cells are given via infusion and multiply in the patient’s blood attacking the cancerous cells. this treatment is also being studied in other cancers, as well as recurring childhood acute lymphocytic leukemia [14]. relapses relapsed acute lymphocytic leukemia refers to when lymphoblastic stem cells become immature white blood cells or blasts. instead of becoming healthy white blood cells they build up in the bone marrow, resulting in less room for healthy white blood cells, red blood cells, and platelets. furthermore, resulting in these abnormal cells the inability to fight off infection [18]. after children’s first treatment for acute lymphocytic leukemia about 85%-90% are cured; however, 10% to 15% of patients with pediatric acute leukemia experience relapse or have a slight chance of getting the disease again [19]. acute lymphocytic leukemia is the most common fatal disease in children, which consists of 25% of all childhood cancers [20]. studies show that most relapsed events occurred during the maintenance phase and after the finalization of chemotherapy [20]. stem cell transplant is rarely used as initial treatment for children and adolescents with all, however it is used more often as part of treatment for all that relapses. occasionally treatment for relapsed all is more intensive and critical than newly diagnosed all. reinduction therapy is received at the time of the first relapse. if the second complete remission is a success, treatment options include: chemotherapy with or without radiation therapy and stem cell (bone marrow) transplantation. prognosis a prognosis is the likely course of an illness after a diagnosis. when it comes to the prognosis of children with acute lymphocytic leukemia, there are numerous crucial determinants. the white blood cell count of a child and their age are prime examples of the many important influential factors. white blood cells, also known as leukocytes, are located in the circulatory system to fight off infections. children with all who have very high white blood cell counts (greater than 50,000 cells per cubic millimeter) when they are diagnosed are at higher risk and need more intensive treatment [21]. an overproduction in white blood cells is a main indicator for certain blood cancers or bone marrow diseases, such as all. in continuation, a pediatric patient’s age is essential to determining their prognosis because of their b-cell count. b-cells, also known as b-lymphocytes, are located in the immune system to produce tumor-specific antigens that stop the development of cancer, such as all. b-cell counts are found by blood tests. children between the ages of 1 and 9 with b-cell all tend to have better cure rates [21]. physicians can plan their pediatric patients' future treatments once they have pediatric patients who have been diagnosed with b-cell all, a rare subtype of all, and know their b-cell count. when pediatric patients’ white blood cell counts and/or their age are reported to clinicians, they are often divided into risk categories classified as low risk to extremely high risk, with higher risk kids receiving more intensive treatment. canales, et al. pediatric acute lymphocytic leukemia https://doi.org/10.47488/dhrp.v2is2.62 dhr proceedings ǀ http://dhrproceedings.org 27 2022, vol. 2 no. s2 23-29 mortality rate what is a mortality rate? a mortality rate is the measure of the frequency of occurrence of death in a defined population during a specified interval. acute lymphocytic leukemia has been found to be the most common form of childhood cancer. it is usually found in children from ages 3 to 5 and it affects boys slightly more than girls [22]. approximately 6,000 cases of acute lymphocytic leukemia (all) cases are diagnosed in the us each year. more than 50% of these cases are in pediatric patients. the five-year mortality rate for pediatric patients diagnosed with all is 10%. even though childhood cancer rates have been increasing, death rates have been drastically decreasing [16]. survival rate a survival rate refers to the percentage of people in a study or treatment group who are still alive for a certain period of time after they were diagnosed with or started treatment for a disease. each year roughly about 6,000 all cases are diagnosed. more than half of these cases are diagnosed in children. 90% of pediatric cases found can be cured [16]. st. jude patients diagnosed with all have a 94% survival rate, which is the best worldwide outcome for all patients. conclusion in closing, acute lymphocytic leukemia (all) is a type of cancer that affects the blood and bone marrow of the body [9]. all is the most common pediatric leukemia, with approximately over 3,000 cases diagnosed in children. even with being the most prevalent leukemia diagnosed in the pediatric group, only about 10% of patients succumb to all [16]. unfortunately, a cure has not been found for this disease. doctors, patients, and all corresponding parties await for more research to stop the progression and cure acute lymphocytic leukemia in all children. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. american cancer society. (n.d.). types of leukemia. american cancer society. retrieved july 18, 2022, from https://www.cancer.org/cancer/leukemia.ht ml. 2. leukemia & lymphoma society. (n.d.). childhood and adolescent blood cancer facts and statistics | leukemia and lymphoma society. leukemia & lymphoma society. retrieved july 18, 2022, from https://www.lls.org/facts-andstatistics/childhood-and-adolescent-bloodcancer-facts-and-statistics. 3. american cancer society. (2019, february 12). what is childhood leukemia? american cancer society. retrieved july 18, 2022, from https://www.cancer.org/cancer/leukemia-inchildren/about/what-is-childhoodleukemia.html. 4. mayo clinic. (2021, january 13). leukemia symptoms and causes. mayo clinic. retrieved july 18, 2022, from https://www.mayoclinic.org/diseasesconditions/leukemia/symptoms-causes/syc20374373. 5. roswell park comprehensive cancer center. (2018, october 4). how fast does leukemia develop? roswell park comprehensive cancer center. retrieved july 15, 2022, from https://www.roswellpark.org/cancertalk/201 810/how-fast-does-leukemia-develop. 6. children's hospital of philadelphia. (n.d.). acute lymphoblastic leukemia (all). children's hospital of philadelphia. retrieved july 15, 2022, from https://www.chop.edu/conditionsdiseases/acute-lymphoblastic-leukemia-all. https://www.cancer.org/cancer/leukemia.html https://www.cancer.org/cancer/leukemia.html https://www.lls.org/facts-and-statistics/childhood-and-adolescent-blood-cancer-facts-and-statistics https://www.lls.org/facts-and-statistics/childhood-and-adolescent-blood-cancer-facts-and-statistics https://www.lls.org/facts-and-statistics/childhood-and-adolescent-blood-cancer-facts-and-statistics https://www.cancer.org/cancer/leukemia-in-children/about/what-is-childhood-leukemia.html https://www.cancer.org/cancer/leukemia-in-children/about/what-is-childhood-leukemia.html https://www.cancer.org/cancer/leukemia-in-children/about/what-is-childhood-leukemia.html https://www.mayoclinic.org/diseases-conditions/leukemia/symptoms-causes/syc-20374373 https://www.mayoclinic.org/diseases-conditions/leukemia/symptoms-causes/syc-20374373 https://www.mayoclinic.org/diseases-conditions/leukemia/symptoms-causes/syc-20374373 https://www.roswellpark.org/cancertalk/201810/how-fast-does-leukemia-develop https://www.roswellpark.org/cancertalk/201810/how-fast-does-leukemia-develop https://www.chop.edu/conditions-diseases/acute-lymphoblastic-leukemia-all https://www.chop.edu/conditions-diseases/acute-lymphoblastic-leukemia-all canales, et al. pediatric acute lymphocytic leukemia https://doi.org/10.47488/dhrp.v2is2.62 dhr proceedings ǀ http://dhrproceedings.org 28 2022, vol. 2 no. s2 23-29 7. american cancer society. (2019, february 12). tests for childhood leukemia. american cancer society. retrieved july 18, 2022, from https://www.cancer.org/cancer/leukemia-inchildren/detection-diagnosis-staging/howdiagnosed.html. 8. wang, e. (2018, october 4). how fast does leukemia develop? roswell park comprehensive cancer center. retrieved july 15, 2022, from https://www.roswellpark.org/cancertalk/201 810/how-fast-does-leukemia-develop. 9. mayo clinic. (2021, february 10). acute lymphocytic leukemia symptoms and causes. mayo clinic. retrieved july 15, 2022, from https://www.mayoclinic.org/diseasesconditions/acute-lymphocyticleukemia/symptoms-causes/syc-20369077. 10. iacobucci, i., & mullighan, c. g. (2017). genetic basis of acute lymphoblastic leukemia. journal of clinical oncology : official journal of the american society of clinical oncology, 35(9), 975–983. https://doi.org/10.1200/jco.2016.70.7836. 11. albertí-servera, l., demeyer, s., govaerts, i., swings, t., de bie, j., gielen, o., brociner, m., michaux, l., maertens, j., uyttebroeck, a., de keersmaecker, k., boeckx, n., segers, h., & cools, j. (2021). single-cell dna amplicon sequencing reveals clonal heterogeneity and evolution in t-cell acute lymphoblastic leukemia. blood, 137(6), 801–811. https://doi.org/10.1182/blood.2020006996. 12. carroll, a. j., shago, m., mikhail, f. m., raimondi, s. c., hirsch, b. a., loh, m. l., raetz, e. a., borowitz, m. j., wood, b. l., maloney, k. w., mattano, l. a., jr, larsen, e. c., gastier-foster, j., stonerock, e., ell, d., kahwash, s., devidas, m., harvey, r. c., chen, i. l., willman, c. l., … heerema, n. a. (2019). masked hypodiploidy: hypodiploid acute lymphoblastic leukemia (all) mimicking hyperdiploid all in children: a report from the children's oncology group. cancer genetics, 238, 62– 68. https://doi.org/10.1016/j.cancergen.2019.07. 009. 13. molina, o., bataller, a., thampi, n., ribera, j., granada, i., velasco, p., fuster, j. l., & menéndez, p. (2021). near-haploidy and low-hypodiploidy in b-cell acute lymphoblastic leukemia: when less is too much. cancers, 14(1), 32. https://doi.org/10.3390/cancers14010032. 14. national cancer institute. (2022, march 4). childhood acute lymphoblastic leukemia treatment (pdq®)–patient version. national cancer institute. retrieved july 13, 2022, from https://www.cancer.gov/types/leukemia/pati ent/child-all-treatment-pdq. 15. barlow, b. (2022, april 29). down's syndrome and leukemia: what to know. medical news today. retrieved july 18, 2022, from https://www.medicalnewstoday.com/articles /aml-down-syndrome#prevalence. 16. md anderson. (2020, april 15). leukemia. md anderson. retrieved july 15, 2022, from https://www.mdanderson.org/cancertypes/leukemia.html?invsrc=leukemia&cmp id=luk_org_leukemiabloodcancer_g_se &gclid=cjwkcajw2rmwbhb4eiwaij0mt yl25xp5jvdwzikl0t127mmftgcd0b6bf9sxae bz0l0ufabrcfweroc2weqavd_bwe&g clsrc=aw.ds. 17. american cancer society. (2019, february 12). high-dose chemotherapy and stem cell transplant for childhood leukemia. american cancer society. retrieved july 15, 2022, from https://www.cancer.org/cancer/leukemia-inchildren/treating/bone-marrow.html. 18. dana-farber cancer institute. (n.d.). relapsed childhood acute lymphoblastic leukemia (all) overview. dana-farber cancer institute. retrieved july 18, 2022, from https://www.dana-farber.org/relapsedchildhood-acute-lymphoblastic-leukemia/. 19. children's hospital of philadelphia. (n.d.). relapsed/refractory acute lymphoblastic https://www.cancer.org/cancer/leukemia-in-children/detection-diagnosis-staging/how-diagnosed.html https://www.cancer.org/cancer/leukemia-in-children/detection-diagnosis-staging/how-diagnosed.html https://www.cancer.org/cancer/leukemia-in-children/detection-diagnosis-staging/how-diagnosed.html https://www.roswellpark.org/cancertalk/201810/how-fast-does-leukemia-develop https://www.roswellpark.org/cancertalk/201810/how-fast-does-leukemia-develop https://www.mayoclinic.org/diseases-conditions/acute-lymphocytic-leukemia/symptoms-causes/syc-20369077 https://www.mayoclinic.org/diseases-conditions/acute-lymphocytic-leukemia/symptoms-causes/syc-20369077 https://www.mayoclinic.org/diseases-conditions/acute-lymphocytic-leukemia/symptoms-causes/syc-20369077 https://doi.org/10.1200/jco.2016.70.7836 https://doi.org/10.1182/blood.2020006996 https://doi.org/10.1016/j.cancergen.2019.07.009 https://doi.org/10.1016/j.cancergen.2019.07.009 https://doi.org/10.3390/cancers14010032 https://www.cancer.gov/types/leukemia/patient/child-all-treatment-pdq https://www.cancer.gov/types/leukemia/patient/child-all-treatment-pdq https://www.medicalnewstoday.com/articles/aml-down-syndrome#prevalence https://www.medicalnewstoday.com/articles/aml-down-syndrome#prevalence https://www.mdanderson.org/cancer-types/leukemia.html?invsrc=leukemia&cmpid=luk_org_leukemiabloodcancer_g_se&gclid=cjwkcajw2rmwbhb4eiwaij0mtyl25x-p5jvdwzikl0t127mmftgcd0b6bf9sxaebz0l0ufabrcfweroc2weqavd_bwe&gclsrc=aw.ds https://www.mdanderson.org/cancer-types/leukemia.html?invsrc=leukemia&cmpid=luk_org_leukemiabloodcancer_g_se&gclid=cjwkcajw2rmwbhb4eiwaij0mtyl25x-p5jvdwzikl0t127mmftgcd0b6bf9sxaebz0l0ufabrcfweroc2weqavd_bwe&gclsrc=aw.ds https://www.mdanderson.org/cancer-types/leukemia.html?invsrc=leukemia&cmpid=luk_org_leukemiabloodcancer_g_se&gclid=cjwkcajw2rmwbhb4eiwaij0mtyl25x-p5jvdwzikl0t127mmftgcd0b6bf9sxaebz0l0ufabrcfweroc2weqavd_bwe&gclsrc=aw.ds https://www.mdanderson.org/cancer-types/leukemia.html?invsrc=leukemia&cmpid=luk_org_leukemiabloodcancer_g_se&gclid=cjwkcajw2rmwbhb4eiwaij0mtyl25x-p5jvdwzikl0t127mmftgcd0b6bf9sxaebz0l0ufabrcfweroc2weqavd_bwe&gclsrc=aw.ds https://www.mdanderson.org/cancer-types/leukemia.html?invsrc=leukemia&cmpid=luk_org_leukemiabloodcancer_g_se&gclid=cjwkcajw2rmwbhb4eiwaij0mtyl25x-p5jvdwzikl0t127mmftgcd0b6bf9sxaebz0l0ufabrcfweroc2weqavd_bwe&gclsrc=aw.ds https://www.mdanderson.org/cancer-types/leukemia.html?invsrc=leukemia&cmpid=luk_org_leukemiabloodcancer_g_se&gclid=cjwkcajw2rmwbhb4eiwaij0mtyl25x-p5jvdwzikl0t127mmftgcd0b6bf9sxaebz0l0ufabrcfweroc2weqavd_bwe&gclsrc=aw.ds https://www.mdanderson.org/cancer-types/leukemia.html?invsrc=leukemia&cmpid=luk_org_leukemiabloodcancer_g_se&gclid=cjwkcajw2rmwbhb4eiwaij0mtyl25x-p5jvdwzikl0t127mmftgcd0b6bf9sxaebz0l0ufabrcfweroc2weqavd_bwe&gclsrc=aw.ds https://www.mdanderson.org/cancer-types/leukemia.html?invsrc=leukemia&cmpid=luk_org_leukemiabloodcancer_g_se&gclid=cjwkcajw2rmwbhb4eiwaij0mtyl25x-p5jvdwzikl0t127mmftgcd0b6bf9sxaebz0l0ufabrcfweroc2weqavd_bwe&gclsrc=aw.ds https://www.cancer.org/cancer/leukemia-in-children/treating/bone-marrow.html https://www.cancer.org/cancer/leukemia-in-children/treating/bone-marrow.html https://www.dana-farber.org/relapsed-childhood-acute-lymphoblastic-leukemia/ https://www.dana-farber.org/relapsed-childhood-acute-lymphoblastic-leukemia/ canales, et al. pediatric acute lymphocytic leukemia https://doi.org/10.47488/dhrp.v2is2.62 dhr proceedings ǀ http://dhrproceedings.org 29 2022, vol. 2 no. s2 23-29 leukemia (all). children's hospital of philadelphia. retrieved july 18, 2022, from https://www.chop.edu/conditionsdiseases/relapsedrefractory-acutelymphoblastic-leukemia-all. 20. tuong, p. n., kiem hao, t., & kim hoa, n. t. (2020). relapsed childhood acute lymphoblastic leukemia: a singleinstitution experience. cureus, 12(7), e9238. https://doi.org/10.7759/cureus.9238. 21. american cancer society. (2019, february 12). prognostic factors in childhood leukemia (all or aml). american cancer society. retrieved july 18, 2022, from https://www.cancer.org/cancer/leukemia-inchildren/detection-diagnosisstaging/prognostic-factors.html. 22. st. jude children's research hospital. (n.d.). acute lymphoblastic leukemia (all). st. jude children's research hospital. retrieved july 15, 2022, from https://www.stjude.org/disease/acutelymphoblastic-leukemia-all.html. https://www.chop.edu/conditions-diseases/relapsedrefractory-acute-lymphoblastic-leukemia-all https://www.chop.edu/conditions-diseases/relapsedrefractory-acute-lymphoblastic-leukemia-all https://www.chop.edu/conditions-diseases/relapsedrefractory-acute-lymphoblastic-leukemia-all https://doi.org/10.7759/cureus.9238 https://www.cancer.org/cancer/leukemia-in-children/detection-diagnosis-staging/prognostic-factors.html https://www.cancer.org/cancer/leukemia-in-children/detection-diagnosis-staging/prognostic-factors.html https://www.cancer.org/cancer/leukemia-in-children/detection-diagnosis-staging/prognostic-factors.html https://www.stjude.org/disease/acute-lymphoblastic-leukemia-all.html https://www.stjude.org/disease/acute-lymphoblastic-leukemia-all.html fourth quarter: vol. 2 no. s4 https://doi.org/10.47488/dhrp.v2is4.75 dhr proceedings ǀ http://dhrproceedings.org 1 2022, vol. 2 no. s4 1-6 commentary sociology of sleep health in the rio grande valley jiya devnani1, deepak srivastava2, and sohail rao3,4 1the village high school, houston, texas (grade 12) orcid id: 0000-0003-0468-7826 2deepak srivastava md, faasm, facp, fccp, rpsgt. professor of medicine, sleep medicine, and critical care, uc davis, orcid id: 0000-0002-7708-4885 3sohail rao, md, ma, dphil. executive vice president for research and leadership development, dhr health system and founding president & ceo, dhr health institute for research & development orcid id: 0000-0001-5027-9992 4corresponding author: sohail rao, md, ma, dphil. dhr health institute for research & development, 5323 s mccoll road, edinburg, tx 78539. e-mail: s.rao@dhr-rgv-com received 10/10/2022 accepted for publication: 10/11/2022 published: 10/11/2022 abstract it is estimated that 50 – 70 million americans have sleep disorders and 1 in 3 (33%) of adults do not regularly get the recommended amount of uninterrupted sleep. several factors contribute to this burgeoning healthcare crisis which has far-reaching consequences at the individual and societal levels. residents in the rio grande valley have been identified as the third most vulnerable population for the prevalence of cardiovascular disease in the country, with obesity being a major identifiable contributory factor. factors that further augment this encumbrance include undiagnosed comorbid sleep disorders. identifying unique socio-cultural challenges in this growing, vibrant population is vital to improve public health outcomes. lack of accessible medical resources, high level of uninsured, poverty, and inadequate sleep health education makes this population extremely vulnerable to the sleep debt crisis with its intended negative outcomes. keywords: sleep disorders, sleep apnea, hispanic, racial disparities introduction sleep is a natural, reversible condition of rest, and inactivity for the body and mind. sleep is when our bodies mend, regenerate, and revitalize. a third of our lifetimes is spent in this universally inescapable physiological state, driven by neurochemical phenomena which is significantly influenced by environmental, social, and personal cues. sleep health is a burgeoning yet neglected health concern; various biological and social variables intertwine to contribute to this burden, which has far-reaching implications at the individual, social, and societal levels. the importance of sleep deprivation impacting cerebral, cardiovascular, metabolic health, and immunity is well documented in the medical literature. obstructive sleep apnea is linked to hypertension, heart disease, stroke, atherosclerosis, and poor glycemic control (1). additionally, sleep interruptions interfere with deep restorative slow-wave sleep, which impacts mental health, memory concentration, and productivity. the amount of sleep one needs changes with age with infants requiring more sleep as compared to the adults https://orcid.org/0000-0003-0468-7826 https://orcid.org/0000-0002-7708-4885 https://orcid.org/0000-0001-5027-9992 mailto:s.rao@dhr-rgv-com fourth quarter: vol. 2 no. s4 https://doi.org/10.47488/dhrp.v2is4.75 dhr proceedings ǀ http://dhrproceedings.org 2 2022, vol. 2 no. s4 1-6 (2, 3). as per the recommendations of the american academy of sleep medicine, infants require 12-16 hours of sleep per day whereas adults aged 18-60 years require over seven hours of sleep per day (table 1). sleep has a bidirectional link between social and environmental influences dictated by interpersonal factors. recognizing the constraints impacting sleep from an economic and sociocultural landscape is vital. the study of upstream socialenvironmental forces that weave a complex framework is critical in identifying key influencers that play a role in healthcare delivery. the rio grande valley (rgv) in south texas is among the fastest growing region in the nation with an estimated population of >1.4 million people. over 90% of the people living in rgv are of hispanic ethnicity; 3040% are uninsured; and >30% live below the poverty line in medically underserved regions. this unique socio-economic and demographic pattern makes it a very vulnerable at-risk population thus requiring strategies with visionary public policy to improve health outcomes. the burden of chronic disease and poor sleep health in the rio grande valley aptly summarizing the urgency of the health crisis, evelia castillo, the coordinator of the “working on wellness program,” declared that, "the valley is ground zero for texas." (4). obesity is significantly more prevalent among hispanics, who constitute >90% of the population. in the lower rgv, almost 40% population is classified as clinically obese which is greater than the state or national levels. equally disconcerting is the high percentage of people in the valley suffering from chronic diseases such as diabetes, liver disorders, cancer, cardiovascular diseases, etc. sleep disorders have been linked to an increased risk of heart failure, glucose intolerance, and cognitive impairment. sleep is a natural, reversible condition of rest, and inactivity for the body and mind. sleep is when our bodies mend, regenerate, and revitalize. a third of our lifetimes are spent in this universally inescapable physiological state, driven by neurochemical phenomena yet significantly influenced by environmental, social, and personal cues. sleep health is a burgeoning yet neglected health concern; various biological and social variables intertwine to contribute to this burden, which has farreaching implications at the individual, social, and societal levels. sleep has a bidirectional link between social and environmental influences dictated by interpersonal factors therefore recognizing the constraints impacting sleep from an economic and sociocultural landscape is vital. the study of upstream social-environmental forces that weave a complex framework is critical in identifying key influencers that play a role in healthcare delivery. methods a literature review spanning 2000-2021 utilizing databases that covered social sciences (assia) and clinical medicine (pubmed, medline) were explored for articles addressing sleep disorders and their adverse health outcomes, disparities, and limitations in access to healthcare with focus on demographically and geographically relevant data. articles were identified that addressed the influence of factors such as race, language, economic challenges, and sociocultural and environmental conditions. results and discussion effects of sleep deprivation it is predicted that 50–70 million americans suffer from chronic sleep and wakefulness disorders, which impede everyday functioning and negatively affect health and longevity. there are over 90 separate sleep disorders, the international classification of sleep disorders has grouped them into six major categories based on clinical symptoms of sleep-related breathing disorders; excessive daytime drowsiness; trouble starting or sustaining sleep; and abnormal behaviors occurring prior to or during sleep (5). the cumulative long-term impacts of sleep deprivation and sleep disorders have been linked to various negative health outcomes, including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. demographics of rio grande valley rgv comprises four counties: cameron, hidalgo, starr, and willacy. residents of the rgv have been recognized as the third most vulnerable in the country to cardiovascular disease, with obesity being a critical risk factor. of the estimated 1.4 million people in the rgv approximately 86% of the population is below the age of 65 years. it is estimated that by 2045, the population in rgv will double to approximately 2.4 – 2.8 million people (6). limited access to and motivation for education is reflected in one-third of over 25-years’ old not having achieved a ninth-grade education as fourth quarter: vol. 2 no. s4 https://doi.org/10.47488/dhrp.v2is4.75 dhr proceedings ǀ http://dhrproceedings.org 3 2022, vol. 2 no. s4 1-6 opposed to the national average of 5 percent. in addition, half and two-thirds of adults have high school diplomas, and area unemployment rates are high, with 30%–40% living below the federal poverty level. in practically every area of educational attainment, cities in rgv ranked “least educated” (7). limited health insurance, lack of public transportation, and lack of easily accessible healthy meals are all contributory factors to poor health outcomes (8). the burden of chronic disease in rgv aptly summarizing the urgency of the health crisis, evelia castillo, the coordinator of the ‘working on wellness program’ declared "the valley is ground zero for texas." obesity is significantly more prevalent among hispanics who constitute >90% of the population in rgv. in the lower rgv, almost 40% population are classified as clinically obese a number far greater than the state or national levels. estimated prevalence of diabetes is 11.6% of adults in south texas higher than the rest of texas [9.3%] (9). south texas hispanics have a higher rate of mortality than hispanics in the remainder of texas. hispanics in south texas experienced a slightly higher rate of mortality from heart disease than non-hispanics. hispanic male mortality from strokes is greater than females in south texas. sleep disorders have been linked to an increased risk of heart failure, glucose intolerance, and cognitive impairment barriers to sleep health "where we sleep, when we sleep, and with whom we sleep are all important markers or indicators of social status, privilege, and prevailing power relations." said william rodrigues cintron (10). obesity, diabetes, residing in the inner city, and alcohol use are all risk factors in hispanics. acculturation to the american way of life may result in worse sleep patterns, including short sleep duration and poor sleep hygiene. is race a risk factor? by 2060, hispanics/latinos are expected to constitute 28% of the us population (figure 1). hispanics are more likely to be uninsured as compared to whites (11). two current nih-sponsored sleep studies on hispanics in the united states promise to significantly contribute to the literature on various sleep disorders such as obstructive sleep apnea, insufficient sleep syndrome, and restless legs syndrome. sleep apnea global interdisciplinary consortium has given insight into the hispanic population's different phenotypic subgroups and gender variations (12). many individuals meeting clinical obstructive sleep apnea criteria could go undiagnosed and subsequently not receive appropriate treatment due to minimum symptoms and presenting complaints. disparities and limitations in access to care: language barriers health knowledge deficits may negatively affect outcomes. spanish is the first language for 79% of the rgv population, and 19% of the population speak english. the inclusion of spanish-speaking healthcare providers can improve health literacy. developing trust among new immigrants is vital in developing continuity of care. high social and health risk factors affect children living in low-income areas. these families should be targeted with early-age and culturally appropriate health programs (13). sociocultural and environmental factors socioeconomically disadvantaged individuals are more likely to sleep in less-thanoptimal environments (e.g., too hot, or too cold, noisy, or crowded). social determinants at individual, societal and social levels impact the framework that influences sleep health. limited access to healthcare and comprehensive behavioral medicine services and ethno-racial disparities also impacts outcomes (14). hispanics were less likely to report insufficient sleep than whites; they also have culturally specific sleep patterns, including siestas. disparities in treatment adherence and outcomes continuous positive airway pressure (cpap) adherence rates in hispanic populations are lower than white populations. at a societal level, limited access to sleep medicine specialists, inequitable distribution healthcare resources, limited support from durable medical equipment providers for troubleshooting and support after cpap initiation as well as language barriers have been identified as contributory factors. at an individual level, there exists mistrust among minorities in the medical system which has been linked to lower medication adherence. unstable housing conditions, frequent changes in sleeping location can predict lower cpap use (15). fourth quarter: vol. 2 no. s4 https://doi.org/10.47488/dhrp.v2is4.75 dhr proceedings ǀ http://dhrproceedings.org 4 2022, vol. 2 no. s4 1-6 clinical implications and the path forward proposed public policy reforms several grass root movements have been initiated to improve collaborative research and enhance population health outcomes. the working on wellness program, a texas a&m university's healthy south texas initiative, is focused on improving preventive community and clinical health care. the valley interprofessional dedicated access and service (vidas) program supports the development and implementation of primary care services for residents in the colonias. the unique role of “promotoras,” who live and work in the communities serving as community advocates and liaisons, educators, mentors, outreach workers, role models, and interpreters is extremely valuable. this emphasis on building relationships within the community is also known as personalismo. expanding the mission of the “unimovil” mobile health clinic to screen for sleep apnea is recommended. unimovil is a revolutionary concept of a mobile clinic focusing on seven clinical outcomes all of which have impact of sleep health. it includes focus on obesity, diabetes, hypertension, hypertriglyceridemia, low high-density lipoprotein cholesterol (hdl-c) levels, and depression utilizing the duke health profile. organizations like lupe and the texas a&m agrilife extension service run similar nutrition education programs tackling the obesity epidemic. the national healthy sleep awareness project launched the pledge to dejar de roncar (stop the snore) to raise awareness among hispanics about adverse health outcomes associated with sleep-breathing disorders. building on the existing social network and disseminating sleep health information, integrating screening for sleep disorders into primary care frameworks, and embracing telemedicine to widen the footprint are vital strategies. a multidisciplinary approach is required to increase targeted healthcare access in a cost-effective, sustainable model with limited resources in a challenging sociocultural landscape. summary strategies with visionary public policy are vital to improving health outcome measures. several grass root movements have been initiated to strengthen collaborative research and enhance population health outcomes. generating social awareness, addressing public safety, and implementing change can improve sleep health and associated comorbidities in predominantly hispanic population in the rgv. funding the project was funded by a seed grant from the dhr health institute for research & development. conflict of interest the authors have reported no conflict of interest references 1. punjabi, n. m. (2004). sleep-disordered breathing, glucose intolerance, and insulin resistance: the sleep heart health study. american journal of epidemiology, 160(6), 521–530. https://doi.org/10.1093/aje/kwh261 2. paruthi s, brooks lj, d'ambrosio c, hall wa, kotagal s, lloyd rm, malow ba, maski k, nichols c, quan sf, rosen cl, troester mm, wise ms. recommended amount of sleep for pediatric populations: a consensus statement of the american academy of sleep medicine. j clin sleep med. 2016 jun 15;12(6):785-6. doi: 10.5664/jcsm.5866. pmid: 27250809; pmcid: pmc4877308. 3. watson nf, badr ms, belenky g, bliwise dl, buxton om, buysse d, dinges df, gangwisch j, grandner ma, kushida c, malhotra rk, martin jl, patel sr, quan sf, tasali e. recommended amount of sleep for a healthy adult: a joint consensus statement of the american academy of sleep medicine and sleep research society. sleep. 2015 jun 1;38(6):843-4. doi: 10.5665/sleep.4716. pmid: 26039963; pmcid: pmc4434546. 4. galvin g. battle on the border. u.s. news & world report. 2018 may 16. https://www.usnews.com/news/healthie st-communities/articles/2018-05-16/abattle-for-community-health-in-texasrio-grande-valley 5. sateia mj. international classification of sleep disorders-third edition: highlights and modifications. chest. 2014 nov;146(5):1387-1394. doi: https://doi.org/10.1093/aje/kwh261 https://jcsm.aasm.org/doi/10.5664/jcsm.5866 https://jcsm.aasm.org/doi/10.5664/jcsm.5866 https://academic.oup.com/sleep/article/38/6/843/2416939?login=false https://www.usnews.com/news/healthiest-communities/articles/2018-05-16/a-battle-for-community-health-in-texas-rio-grande-valley https://www.usnews.com/news/healthiest-communities/articles/2018-05-16/a-battle-for-community-health-in-texas-rio-grande-valley https://www.usnews.com/news/healthiest-communities/articles/2018-05-16/a-battle-for-community-health-in-texas-rio-grande-valley https://www.usnews.com/news/healthiest-communities/articles/2018-05-16/a-battle-for-community-health-in-texas-rio-grande-valley https://journal.chestnet.org/article/s0012-3692(15)52407-0/fulltext fourth quarter: vol. 2 no. s4 https://doi.org/10.47488/dhrp.v2is4.75 dhr proceedings ǀ http://dhrproceedings.org 5 2022, vol. 2 no. s4 1-6 10.1378/chest.14-0970. pmid: 25367475. 6. gomez r, guajardo l, and ely-ledesma e. it is time to recognize the rio grande valley as a rising borderland metropolis. tice university kinder institute for urban research. 2022 jun 15. https://kinder.rice.edu/urbanedge/ittime-recognize-rio-grande-valleyrising-borderlandmetropolis#:~:text=the%20population %20in%20the%20rgv%20is%20proje cted%20to,they%20form%20one%20ec onomic%2c%20social%2c%20and%2 0ecological%20region. 7. mccann a. most and least educated cities in america. wallethub. 2022 jul 18. https://wallethub.com/edu/e/mostand-least-educated-cities/6656 8. hargraves, j. l., & hadley, j. (2003). the contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care. health services research, 38(3), 809–829. https://doi.org/10.1111/14756773.00148 9. johnson, e. p., dunn, m., cooper, m., & bhakta, n. (2019). diabetes prevention program sites compared with diabetes prevalence and ratio of primary care physicians in texas. preventing chronic disease, 16, 190175. https://doi.org/10.5888/pcd16.190175 10. cintron wr. when we sleep, where we sleep, and with whom we sleep are all important markers or indicators of social status, privilege, and health. j clin sleep med. 2020 feb 15;16(2):163. doi: 10.5664/jcsm.8262. epub 2020 jan 13. pmid: 31992431; pmcid: pmc7053039. 11. loredo, j. s., soler, x., bardwell, w., ancoli-israel, s., dimsdale, j. e., & palinkas, l. a. (2010). sleep health in u.s. hispanic population. sleep, 33(7), 962–967. https://doi.org/10.1093/sleep/33.7.962 12. gonzález ka, tarraf w, wallace dm, stickel am, schneiderman n, redline s, patel sr, gallo lc, mossavar-rahmani y, daviglus ml, zee pc, talavera ga, sotres-alvarez d, gonzález hm, ramos a. phenotypes of obstructive sleep apnea in the hispanic community health study/study of latinos. sleep. 2021 dec 10;44(12):zsab181. doi: 10.1093/sleep/zsab181. pmid: 34272952; pmcid: pmc8664595. 13. halbert, c. h., armstrong, k., gandy, o. h., & shaker, l. (2006). racial differences in trust in health care providers. archives of internal medicine, 166(8), 896. https://doi.org/10.1001/archinte.166.8.8 96 14. gaskin, d. j., dinwiddie, g. y., chan, k. s., & mccleary, r. (2012). residential segregation and disparities in health care services utilization. medical care research and review, 69(2), 158–175. https://doi.org/10.1177/1077558711420 263 15. borker, p. v, carmona, e., essien, u. r., saeed, g. j., nouraie, s. m., bakker, j. p., stitt, c. j., aloia, m. s., & patel, s. r. (2021). neighborhoods with greater prevalence of minority residents have lower continuous positive airway pressure adherence. american journal of respiratory and critical care medicine, 204(3), 339–346. https://doi.org/10.1164/rccm.2020093685oc https://journal.chestnet.org/article/s0012-3692(15)52407-0/fulltext https://kinder.rice.edu/urbanedge/it-time-recognize-rio-grande-valley-rising-borderland-metropolis#:~:text=the%20population%20in%20the%20rgv%20is%20projected%20to,they%20form%20one%20economic%2c%20social%2c%20and%20ecological%20region https://kinder.rice.edu/urbanedge/it-time-recognize-rio-grande-valley-rising-borderland-metropolis#:~:text=the%20population%20in%20the%20rgv%20is%20projected%20to,they%20form%20one%20economic%2c%20social%2c%20and%20ecological%20region https://kinder.rice.edu/urbanedge/it-time-recognize-rio-grande-valley-rising-borderland-metropolis#:~:text=the%20population%20in%20the%20rgv%20is%20projected%20to,they%20form%20one%20economic%2c%20social%2c%20and%20ecological%20region https://kinder.rice.edu/urbanedge/it-time-recognize-rio-grande-valley-rising-borderland-metropolis#:~:text=the%20population%20in%20the%20rgv%20is%20projected%20to,they%20form%20one%20economic%2c%20social%2c%20and%20ecological%20region https://kinder.rice.edu/urbanedge/it-time-recognize-rio-grande-valley-rising-borderland-metropolis#:~:text=the%20population%20in%20the%20rgv%20is%20projected%20to,they%20form%20one%20economic%2c%20social%2c%20and%20ecological%20region https://kinder.rice.edu/urbanedge/it-time-recognize-rio-grande-valley-rising-borderland-metropolis#:~:text=the%20population%20in%20the%20rgv%20is%20projected%20to,they%20form%20one%20economic%2c%20social%2c%20and%20ecological%20region https://kinder.rice.edu/urbanedge/it-time-recognize-rio-grande-valley-rising-borderland-metropolis#:~:text=the%20population%20in%20the%20rgv%20is%20projected%20to,they%20form%20one%20economic%2c%20social%2c%20and%20ecological%20region https://kinder.rice.edu/urbanedge/it-time-recognize-rio-grande-valley-rising-borderland-metropolis#:~:text=the%20population%20in%20the%20rgv%20is%20projected%20to,they%20form%20one%20economic%2c%20social%2c%20and%20ecological%20region https://wallethub.com/edu/e/most-and-least-educated-cities/6656 https://wallethub.com/edu/e/most-and-least-educated-cities/6656 https://doi.org/10.1111/1475-6773.00148 https://doi.org/10.1111/1475-6773.00148 https://doi.org/10.5888/pcd16.190175 https://jcsm.aasm.org/doi/10.5664/jcsm.8262 https://jcsm.aasm.org/doi/10.5664/jcsm.8262 https://doi.org/10.1093/sleep/33.7.962 https://academic.oup.com/sleep/article-abstract/44/12/zsab181/6323310?redirectedfrom=fulltext&login=false https://academic.oup.com/sleep/article-abstract/44/12/zsab181/6323310?redirectedfrom=fulltext&login=false https://doi.org/10.1001/archinte.166.8.896 https://doi.org/10.1001/archinte.166.8.896 https://doi.org/10.1177/1077558711420263 https://doi.org/10.1177/1077558711420263 https://doi.org/10.1164/rccm.202009-3685oc https://doi.org/10.1164/rccm.202009-3685oc fourth quarter: vol. 2 no. s4 https://doi.org/10.47488/dhrp.v2is4.75 dhr proceedings ǀ http://dhrproceedings.org 6 2022, vol. 2 no. s4 1-6 table 1. recommended hours of sleep for various age groups age age group recommended hours of sleep 4-12 months infant 12-16 hours per 24 hours 1-2 years toddler 11-14 hours per 24 hours 3-5 years pre-school 10-13 years per 24 hours 6-12 years school age 9-12 hours per 24 hours 13-18 years teen 13-18 ours per 24 hours >18 years adults >7hours per night figure 1. projected hispanic population growth (in percentage) by year 2060 in the united states* *adapted from united states census bureau. (https://www.census.gov/library/visualizations/2018/comm/hispanicprojected-pop.html) 19 20 21 22 23 25 26 27 28 0 5 10 15 20 25 30 2020 2025 2030 2035 2040 2045 2050 2055 2060 https://www.census.gov/library/visualizations/2018/comm/hispanic-projected-pop.html https://www.census.gov/library/visualizations/2018/comm/hispanic-projected-pop.html special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.100 dhr proceedings ǀ http://dhrproceedings.org 93 2023, vol. 2 no. s2 93-97 commentary conditions associated with autism yarely martinez1,2, dianna cid1,2, lyzzette hinojosa1,2, artemio belmontes1,2, orlando reyes1,2, sarahi gonzalez1,2, sara de leon1,2, kiveli torres1,3, arianna reyna1,3, ashley solis1,4, judith gomez1,4, trista valdez1,4 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 roma high school isd 3 zapata high school isd 4 weslaco east high school isd received: november 2, 2023 accepted for publication: november 3, 2023 published: november 30, 2023 introduction autism spectrum disorder (asd) is a prevalent neurodevelopmental condition that is found to be relatively misunderstood. in 1911, eugen bleuler, a german psychiatrist, initially believed people with autism suffered from schizophrenia and hallucinations; however, during the 1970s, child psychologists believed that rather than suffering from any sort of hallucinations, the children were simply lacking an unconscious symbolic life.1 with further research and experimentation, psychiatrists redefined “autism”(1). heterogeneous neurodevelopmental condition is the proper term for what happens neurologically for those with asd.2 the way professionals determine whether or not someone has autism is not through a work of tests, but rather, observation of the person's developmental behaviors.2 there are many types of autism, and include “highfunctioning autism” such as asperger's syndrome, and “low-functioning autism” such as autism spectrum disorder (asd). data from the centers for disease control and prevention, show there is an increased risk of autism if bared over a certain age.3 the increased risk of being treated differently, increased risk of aggression amongst others and self, found ⅕ higher mortality rate amongst those on the autism spectrumr.4 there are many psychological and mental conditions associated with asd. a few conditions include, and not limited to obsessive-compulsive disorder (ocd), anxiety, attention deficit hyperactivity disorder (adhd), depression, and eating disorders.4 depression and anxiety one of the main factors of having autism is dealing with anxiety and depression; which is the most common mental illness found in children with autism.5 the most frequent co-occurring condition in children with autism spectrum disorders is anxiety, however, the possible effects of anxiety on social and educational results of these kids hasn’t been carefully investigated. children with high functioning autism (hfa) are a bit more likely to get anxiety, and children who are diagnosed with low functioning autism (lfa) are more prone to depression.5 the rate of death by suicide has sky-rocketed by 7 ½ times in people with autism than those without an autism diagnosis.6 the increased suicide rate in autism may be due to a vast increase in symptoms of depression because autistic people have been shown to quadruple in lifetime rates of depression.7 anxiety is mostly measured using subscales from behavioral instruments, which usually do not describe the range of anxiety symptoms in children with autism spectrum. depression and anxiety symptoms are shown among individuals with autism spectrum disorders (asds) of various ages and iqs, and depression/anxiety symptoms are associated with higher iqs and fewer asd symptoms.8 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.100 dhr proceedings ǀ http://dhrproceedings.org 94 2023, vol. 2 no. s2 93-97 symptoms of anxiety in children with autism vary from temper tantrums to self-injury, frequent running and climbing, hyperactivity, sleep problems, problems socializing, and attention deficit (8). common symptoms of depression in children with autism include difficulty communicating, which gives them a higher risk for suicidal self-harm, suicidal thoughts, further suicidal ideas, and more repetitive/compulsive behavior.8 depression symptoms in children partially explain this association. a non-drug anxiety treatment helping children with autism-linked depression is cognitive behavioral therapy. cbt’s goal is to change how children with autism think about themselves which ultimately helps reduce the negative thoughts/responses.8 cbt is used to address some of the common characteristics of autism. these changes include using pictures, concrete language, lists, videos, or social stories, and involving the special interests the children with autism may have.9 antidepressants can also be used to treat anxiety and obsessive-compulsive disorders however, children and teens who have autism often report side effects from those drugs including “behavioral activation,” such as hyperactivity, impulsiveness, or trouble sleeping.9 an analysis of 14 studies involving a total of 511 autistic youth found that individual and group cbt therapy decreased anxiety symptoms moderately.9 the studies all involved children and teens who did not have intellectual disabilities. the cbt programs, with child-friendly names like cool kids and facing fears, typically lasted from 12 to 16 weeks.9 in another small study of adapted cbt, almost a third of children with autism who completed group therapy at a hospital were found to be “free of their primary anxiety diagnoses”.9 ocd and adhd according to research, adhd is known to be the most common coexisting condition in children with asd.9 ocd is also a common disorder seen in children with asd and they have a high comorbidity.12 ocd as well as adhd, are both common in males who are in their childhood but are more common among women in adolescence and adulthood.13 one significant factor common to both adhd and ocd is the mental incapability to perform certain functioning challenges. both adhd and ocd can affect the child’s ability to control impulse, decision-making, behavior, movement, and social skills.10 identifying which condition a child with asd has is difficult due to the similarities in both cooccurring disorders.11 if a child is diagnosed with ocd, studies show that around 40% of symptoms start to disappear as they reach adulthood.14 if a child is diagnosed with adhd, there is about a 50% chance of the child “outgrowing” their symptoms and behavior with the proper care (14). however, this can differ for each child due to their cognitive function and how severe their asd may be.14 studies have demonstrated that approximately 1 in 8 children diagnosed with adhd were also diagnosed with asd.15 another study was done with a total of 41,382 children with asd , of which 14,109 were diagnosed with asd and adhd.13 studies show that about 1 in 5 children are inclined to have both asd and ocd (16). in addition, boys are more likely to be diagnosed with both asd and adhd or asd and ocd than girls are.15 some common symptoms for children who have asd and ocd consist of compulsive behaviors, repetitive behaviors, and difficulty with change. examples of these symptoms that children with asd and ocd have are propensity to wear certain clothes, lining up toys in a certain way, or engaging in specific routines and rituals, intense focus/difficulty focusing, excessive sensory, and impulsivity/hyperactivity, talk excessively and interrupt conversations.14,15 a psychiatrist can diagnose and treat the child. common treatments for a child with autism and adhd are ritalin and concerta. these medications can help reduce hyperactive behavior in some autistic children.17 the best treatment for ocd that helps a child is exposure response prevention therapy and cognitive-behavioral therapy. erp is a type of therapy that slowly exposes people to situations created to provoke a person’s obsession with a safe environment.19 cbt is the most effective treatment for mental health disorders, cbt is a treatment that aims to change thinking patterns.15 eating disorders children can be known to be picky eaters, more so. in refekids that are diagnosed with asd. parents with autistic children are worried and stressed because their children are more limited to the types of food they can eat. the parents worry about the special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.100 dhr proceedings ǀ http://dhrproceedings.org 95 2023, vol. 2 no. s2 93-97 nutrition of their kids and how they’ll be able to get all the nutrients they need a recent study has shown that parents with children who have asd tend to be more stressed and worried because their children are very selective with their food and the quality of the child's diet is affected.19 feeding difficulties and food selectivity are very common in general but statistically it shows 62% of children that have asd will have a greater unhealthy eating habits.19 children with asd can exhibit feeding difficulties and abnormal eating behaviors related to their asd symptom. children with asd are also exposed to other conditions such as an avoidant/restrictive food intake in which a child refuses to eat. children with asd also have problems with communication that can result in trouble understanding the feeding needs of the child such as if they are hungry, full, or what their food preferences are.20 there are factors linked with feeding disorders in children with asd that are considered to be multifactorial like sensory, behavioral, and psychological. research has shown that if you have a food disorder, it may both be a cause and conceptualization of asd.20 there are different types of eating disorders and their differences are important to recognize. pica is a disorder where a person swallows non-food items without even knowing.21 the items that are consumed are non-nutritional and can be toxic to the body. pica does not only affect people with autism and their mental disorders but children, pregnant women and other types of mental disorders as well. it is a very common condition but is not always detected. treatments can differ from person to person but it usually involves a combination of psychological therapy, nutrition education, monitoring and medications.22 professionals who specialize in eating disorders like a mental health professional can provide psychological therapy and a dietitian can provide education on nutrition. treatment plans involve setting goals, treating physical conditions, finding affordable plans and discovering resources. therapy can last either a few months or years and include different types of therapy like cognitive behavioral therapy, family based therapy and group cognitive behavioral therapy, either alone or in combination.22 conclusion it has been scientifically proven that many children with autism ranging from ages two to twelve have experienced or have been associated with some form of mental health disorder. in studies, as their age and iq increased throughout the years, depression and anxiety were found to have an insignificant increase, and with such a rise in individuals with fewer asd (autism spectrum disorder) symptoms. the symptoms associated with depression and anxiety they were temper tantrums, self-injuries, hyperactivity, sleep problems, suicidal self-harm, suicidal thoughts, and further repetitive thought disorder. a common treatment used is cognitive behavioral therapy, yet there are still other antidepressant medications available. the second most common mental disorders in autistic children are ocd and adhd; ocd is very common in children with asd having a high comorbidity rate, while up to a quarter of children with adhd accompany low signs of asd. symptoms of ocd range from following specific routines, wearing certain clothes, lining up toys, etc., while adhd is talking excessively, constantly fidgeting, and moving/hyperactivity. treatments include ritalin and concerta. eating disorders may also affect children with autism as they are associated with suppressing thoughts and emotions. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. evans, b. (2013). how autism became autism: the radical transformation of a central concept of child development in britain. history of the human sciences, 26(3), 3-31. https://doi.org/10.1177/0952695113484320 2. jacob, s., wolff, j. j., steinbach, m. s., doyle, c. b., kumar, v., & elison, j. t. (2018). neurodevelopmental heterogeneity and computational approaches for https://doi.org/10.1177/0952695113484320 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.100 dhr proceedings ǀ http://dhrproceedings.org 96 2023, vol. 2 no. s2 93-97 understanding autism. translational psychiatry, 9. https://doi.org/10.1038/s41398-019-0390-0 3. amaral, d. g. (2017). examining the causes of autism. cerebrum: the dana forum on brain science, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc5501015/ 4. cage, e., monaco, j. d., & newell, v. (2017). experiences of autism acceptance and mental health in autistic adults. journal of autism and developmental disorders, 48(2), 473-484. https://doi.org/10.1007/s10803-017-3342-7 5. mayes sd, calhoun sl, murray mj, zahid j. variables associated with anxiety and depression in children with autism. journal of developmental and physical disabilities. 2011;23(4):325-337. doi:https://doi.org/10.1007/s10882-0119231-7 6. casten, lucas g., et al. “the combination of autism and exceptional cognitive abilityincreases risk for suicidal ideation.” biorxiv, 2022, p. 2022.02.17.22271086, doi:10.1101/2022.02.17.22271086. 7. whitney dg, shapiro dn, peterson md, warschausky sa. factors associated with depression and anxiety in children with intellectual disabilities. journal of intellectual disability research. 2018;63(5):408-417. doi:https://doi.org/10.1111/jir.12583 8. diagnosing and treating anxiety in people with autism. spark for autism. published july 9, 2020. https://sparkforautism.org/discover_article/d iagnosing-treating-anxiety-autism/ 9. adhd and autism spectrum disorder. chadd. accessed july 20, 2023. https://chadd.org/about-adhd/adhd-andautism-spectrum-disorder/. 10. autism and mental health. weww.mentalhealth.org.uk. https://www.mentalhealth.org.uk/exploremental-health/a-z-topics/autism-and-mentalhealth#:~:text=however%2c%20according %20to%20the%20autism 11. andersen r. autism and adhd: overlaps and differences. autism parenting magazine. june 15, 2022. accessed july 20, 2023. https://www.autismparentingmagazine.com/l earn-autism-differences/. 12. mosner mg, kinard jl, shah js, et al. rates of co-occurring psychiatric disorders in autism spectrum disorder using the mini international neuropsychiatric interview. journal of autism and developmental disorders. september 2019. accessed july 20, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc6669096/?report=reader. 13. “childhood adhd and childhood ocd: what’s the difference?” webmd, https://www.webmd.com/addadhd/childhood-adhd/adhd-andocd#:~:text=studies%20show%20that%20a bout%20one,more%20adult%20patterns%2 0of%20ocd 14. why is ocd so common in children with autism? the facts! applied behavioral analysis | how to become an applied behavior analyst. june 1, 2022. accessed july 20, 2023. https://www.appliedbehavioranalysisedu.org /why-is-ocd-so-common-in-children-withautism/. 15. learn about attention-deficit / hyperactivity disorder (adhd). centers for disease control and prevention. march 30, 2023. accessed july 20, 2023. https://www.cdc.gov/ncbddd/adhd/index.ht ml#:~:text=people%20with%20adhd%20 may%20have,improve%20as%20the%20chi ld%20ages. 16. cherney k. concerta vs. ritalin: dosage differences and more. healthline. may 19, 2023. accessed july 20, 2023. https://www.healthline.com/health/adhd/con certa-ritalin. 17. everything you need to know about exposure and response prevention therapy. a guide to exposure and response prevention therapy | mclean hospital. june 8, 2023. accessed july 20, 2023. https://www.mcleanhospital.org/essential/er p#:~:text=what%20is%20exposure%20and %20response,remove%20distressing%20sit uations%20and%20thoughts. 18. andersen r. autism and adhd: differences, diagnosis and management. autism parenting magazine. published november 7, 2023. https://www.autismparentingmagazine .com/learn-autism-differences/ 19. a guide to exposure and response prevention therapy | mclean hospital. published june 8, 2023. https://www.mcleanhospital.org/essen tial/erp#:~:text=what%20is%20exposure% 20and%20response,remove%20distressing %20situations%20and%20thoughts https://doi.org/10.1038/s41398-019-0390-0 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5501015/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5501015/ https://doi.org/10.1007/s10803-017-3342-7 https://doi.org/10.1007/s10882-011-9231-7 https://doi.org/10.1007/s10882-011-9231-7 https://sparkforautism.org/discover_article/diagnosing-treating-anxiety-autism/ https://sparkforautism.org/discover_article/diagnosing-treating-anxiety-autism/ https://chadd.org/about-adhd/adhd-and-autism-spectrum-disorder/ https://chadd.org/about-adhd/adhd-and-autism-spectrum-disorder/ https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/autism-and-mental-health#:~:text=however%2c%20according%20to%20the%20autism https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/autism-and-mental-health#:~:text=however%2c%20according%20to%20the%20autism https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/autism-and-mental-health#:~:text=however%2c%20according%20to%20the%20autism https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/autism-and-mental-health#:~:text=however%2c%20according%20to%20the%20autism https://www.autismparentingmagazine.com/learn-autism-differences/ https://www.autismparentingmagazine.com/learn-autism-differences/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6669096/?report=reader https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6669096/?report=reader https://www.webmd.com/add-adhd/childhood-adhd/adhd-and-ocd#:~:text=studies%20show%20that%20about%20one,more%20adult%20patterns%20of%20ocd https://www.webmd.com/add-adhd/childhood-adhd/adhd-and-ocd#:~:text=studies%20show%20that%20about%20one,more%20adult%20patterns%20of%20ocd https://www.webmd.com/add-adhd/childhood-adhd/adhd-and-ocd#:~:text=studies%20show%20that%20about%20one,more%20adult%20patterns%20of%20ocd https://www.webmd.com/add-adhd/childhood-adhd/adhd-and-ocd#:~:text=studies%20show%20that%20about%20one,more%20adult%20patterns%20of%20ocd https://www.webmd.com/add-adhd/childhood-adhd/adhd-and-ocd#:~:text=studies%20show%20that%20about%20one,more%20adult%20patterns%20of%20ocd https://www.appliedbehavioranalysisedu.org/why-is-ocd-so-common-in-children-with-autism/ https://www.appliedbehavioranalysisedu.org/why-is-ocd-so-common-in-children-with-autism/ https://www.appliedbehavioranalysisedu.org/why-is-ocd-so-common-in-children-with-autism/ https://www.cdc.gov/ncbddd/adhd/index.html#:~:text=people%20with%20adhd%20may%20have,improve%20as%20the%20child%20ages https://www.cdc.gov/ncbddd/adhd/index.html#:~:text=people%20with%20adhd%20may%20have,improve%20as%20the%20child%20ages https://www.cdc.gov/ncbddd/adhd/index.html#:~:text=people%20with%20adhd%20may%20have,improve%20as%20the%20child%20ages https://www.cdc.gov/ncbddd/adhd/index.html#:~:text=people%20with%20adhd%20may%20have,improve%20as%20the%20child%20ages https://www.healthline.com/health/adhd/concerta-ritalin https://www.healthline.com/health/adhd/concerta-ritalin https://www.mcleanhospital.org/essential/erp#:~:text=what%20is%20exposure%20and%20response,remove%20distressing%20situations%20and%20thoughts https://www.mcleanhospital.org/essential/erp#:~:text=what%20is%20exposure%20and%20response,remove%20distressing%20situations%20and%20thoughts https://www.mcleanhospital.org/essential/erp#:~:text=what%20is%20exposure%20and%20response,remove%20distressing%20situations%20and%20thoughts https://www.mcleanhospital.org/essential/erp#:~:text=what%20is%20exposure%20and%20response,remove%20distressing%20situations%20and%20thoughts special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.100 dhr proceedings ǀ http://dhrproceedings.org 97 2023, vol. 2 no. s2 93-97 20. cermak sa, curtin c, bandini lg. food selectivity and sensory sensitivity in children with autism spectrum disorders. j am diet assoc. 2010;110(2):238-246. doi:10.1016/j.jada.2009.10.032 21. cleveland clinic. pica: what it is, causes, symptoms & treatment. cleveland clinic. published may 6, 2022. https://my.clevelandclinic.org/health/disease s/22944-pica 22. mayo clinic. eating disorder treatment: know your options. mayo clinic. published july 14, 2017. https://my.clevelandclinic.org/health/diseases/22944-pica https://my.clevelandclinic.org/health/diseases/22944-pica special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.94 dhr proceedings ǀ http://dhrproceedings.org 1 2023, vol. 3 no. s1 1--5 commentary bridging the gap: integrating artificial intelligence into medical education adhira tippur1 1mathematics and science academy at the university of texas rio grande valley, edinburg, tx received: august 15, 2023 accepted for publication: september 26, 2023 published: october 10, 2023 introduction artificial intelligence (ai) is rapidly becoming an integral part of our lives (1), seamlessly integrated into numerous technologies in use today (2). its presence spans from the smartphones we carry to the algorithms driving our social media streams. take, for instance, google maps, a remarkable aidriven tool adeptly guiding us to different destinations, showcasing its exceptional navigational prowess in our daily experiences. these ai capabilities, when integrated with our technologies, make our lives more efficient and seamless. this can also be seen in medical settings, where ai-enhanced systems augment the capabilities of medical personnel in diagnosing and treating an extensive array of medical conditions. moreover, ai solutions play a significant role in optimizing operational efficiency with healthcare institutions, encompassing both medicinal functions and administrative responsibilities within hospitals (3). with ai growing rapidly, it is increasingly finding its place in medical educational systems. aspiring medical professionals engage in activities such as patient interaction and research, where ai subtly and visibly enriches the educational journey (4). however, this profound integration prompts multifaceted discussions within the medical education community (5). while advocates commend ai for its potential to enhance learning outcomes by offering adaptive and tailored educational pathways (6), concerns also arise about striking the right balance between ai-assisted learning and the acquisition of hands-on clinical skills (7). this paper delves deeper into the role ai plays in the current medical education system. current applications of ai in medical education given the expanding scope of medical knowledge, integrating technologies like ai into medical education is imperative, especially considering its transformative potential in medical imaging, diagnosis, and treatment (figure 1). this integration offers a pivotal avenue for healthcare professionals to apply evolving medical insights in their practices. consequently, cultivating a profound understanding of this emerging technology becomes indispensable for medical experts in the present context. specifically, in the field of medical education, this comprehensive training encompasses not only mastering the technology itself but also delving into its current merits, which include benefits related to costefficiency, enhanced healthcare quality, and improved accessibility (8). in the current environment, ai's role in medical education predominantly revolves around its capacity to deliver personalized feedback, thereby providing tailored learning support (9). however, there is limited emphasis on refining curricula and effectively assessing student progress in academic settings. this limitation is intricately linked to ongoing challenges stemming from incomplete digitalization within education and the intricate nature of assessments, both of which demand astute management. a study by lee et al. introduces a special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.94 dhr proceedings ǀ http://dhrproceedings.org 2 2023, vol. 3 no. s1 1--5 holistic curriculum and professional development framework meticulously tailored for educators (10). this curriculum focuses on specific categorizations under ai methods in data science. specifically, it aims to expose learners to numerous ai methods through a structured curriculum divided into five distinct units: data analytics, logic systems (using human-readable rules), machine learning (experienced-based model building), supervised learning (utilizing neural networks), and transfer learning (using k nearest neighbor algorithm). each unit consists of five lessons carefully designed to guide learners through various stages of understanding. starting with hands-on experiential learning, these lessons gradually lead to the clarification of key concepts including statistical analysis, creating ai models, and visualizing data. they also include practical exercises conducted in google colab. this proactive approach, precisely attuned to its respective context, aims to empower instructors with a nuanced grasp of ai intricacies, heightening their sensitivity to the multifaceted ethical dimensions inherent in ai, ranging from bias to accountability. impressively, this study underscores the successful infusion of ai into stem classrooms, as validated by the enthusiastic endorsement of educators who actively engaged with modular curriculum units. in another study, it was observed that four distinct ai techniques (including machine learning, deep learning, robotic skills training, and virtual reality) are currently employed across various medical education domains, with a notable focus within training laboratory environments (11). specifically, these techniques were utilized in behavioral health, ophthalmology, orthopedics, surgery, surgery/medicine, and training labs. this shows the diverse areas of implementation in current medical education—demonstrating ai’s potential to further develop and refine certain medical practices (including surgical skills). letting students practice their abilities in simulated situations provides them with the perfect avenue to better understand what patients might be feeling emotionally and mentally, while also fostering effective communication and listening skills. for instance, in ophthalmology, the integration of machine learning and deep learning proved to be instrumental in aiding students with the recognition of numerous eye-associated diseases, primarily through medical imaging analysis. this helps students identify patterns and improve their decision-making abilities, ultimately improving medicinal diagnostic precision. therefore, amid ongoing technological evolution, integrating ai into medical education offers transformative potential, shaping the learning journey for future healthcare practitioners. figure 1: various applications of artificial intelligence in medicine. created with biorender.com benefits and challenges of ai in medical education benefits positioning the upcoming generation of medical practitioners to participate in the evolving data science revolution by acquiring pertinent machine learning techniques stands as one of the notable benefits of ai in medical education (12). some of these techniques include essential tools such as predictive analytics and image detection. specifically, students may initially encounter machine learning through specialized courses in population health and evidence-based medicine. in such contexts, machine learning serves as a supplementary tool for clinicians, enhancing their healthcare delivery. furthermore, technology's adoption opens new opportunities for specific student groups, expanding accessibility and engagement for part-time students and offering tailored programs for gifted or talented students (13). highlighting ai's transformative role in education, another study emphasizes its potential to provide personalized learning assistance, aligning with individual preferences and progress (14). moreover, this examination supports the notion that enhancing healthcare quality is achievable by empowering medical professionals to reach their full potential (7). by incorporating ai-based applications into medical education and training, this empowerment journey for numerous medical workers can be further facilitated. in fact, after implementing ai-based training, noticeable enhancements in practical skills were observed among medical students (11). special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.94 dhr proceedings ǀ http://dhrproceedings.org 3 2023, vol. 3 no. s1 1--5 challenges integrating ai into medical education presents several challenges. many instructors may require additional training to adeptly employ technology and enrich the educational experience (15). the development of nascent technology, particularly when intended for educational purposes, often entails substantial expenses and demands a diverse range of expertise (13). this expertise includes ai algorithm development (designing algorithms tailored to medical content), data analytics (collecting, processing, and interpreting ai-generated medical education data), educational technology integration (seamlessly integrating ai into existing curricula), and instructional design (creating engaging learning experiences). additionally, embedding ai into education can pose difficulties given its interdisciplinary nature and reliance on technology (14). among these challenges, as evidenced by 17 studies, six indicated the presence of early-stage prototypes with technical constraints requiring refinement to enhance the user experience (16). these constraints include aspects such as performance enhancement, efficacy validation, and ai computational processes. regarding the efficacy of ai applications in medical education, a study emphasized the importance of diverse evaluation methods and ample sample sizes to validate replicability. this is crucial due to the challenges surrounding effective ai implementational methods, constraints related to available curriculum hours, and limited faculty expertise (17). furthermore, complications arise in training ai algorithms due to constraints such as limited sample sizes, data integrity, and privacy considerations (18). moreover, concerns have been brought up regarding the interpretability, generalizability, and potential overfitting of ai algorithms (18). navigating these challenges underscores the significance of a comprehensive understanding of ai's potential and limitations is vital for effective integration in medical education. future prospects and considerations significant changes are reshaping medical practice due to the progress of cutting-edge technologies and artificial intelligence (ai). this swift and ground-breaking evolution has underscored the growing necessity for a comprehensive educational curriculum that effectively imparts insights to medical students about the possibilities and capabilities of ai in the healthcare domain (19). in medical education, it's crucial to prioritize essential skills such as statistical competence and empathy. aspiring medical students must prepare themselves for an innovative educational paradigm driven by ai and machine learning (20). leveraging advanced technology for student-directed learning involves active participation through customization, social engagement, and easy access to resources (5). while technology holds the potential to transform medical education, it's vital to acknowledge that ai cannot replace human proficiency and discernment (21). the guidance of experienced practitioners remains indispensable for medical students to develop clinical skills and gain profound subject comprehension (22). recommendations for effective ai integration even though ai has rapidly progressed, there is a scarcity of readily available literature to help medical students grasp its concepts. existing ai resources often assume technical expertise, leaving medical students without essential fundamental knowledge (23). therefore, to facilitate the seamless integration of ai in the medical field, it is imperative to implement strategies that incorporate ai into the medical school syllabus (9). this proactive step will equip medical professionals with a foundational understanding of ai algorithms, enabling them to optimize the use of this transformative technology. in the context of enhancing patient care through adept information technology use, integrating machine learning-related material can be seamlessly woven into a comprehensive curriculum (12). this strategic approach ensures a holistic framework that emphasizes competence and skill development. additionally, it's crucial to highlight that while ai offers diverse advantages, its integration into healthcare raises ethical considerations concerning data privacy, automation, and telehealth (24). the lack of well-defined guidelines can result in challenges during implementation, emphasizing the importance of establishing a set of rules to be followed. conclusion and discussion artificial intelligence (ai) has profoundly permeated various aspects of our lives, revolutionizing technologies and offering unparalleled advantages. this transformative impact extends to medical education, where ai-enhanced systems are reshaping how medical professionals diagnose, treat, and optimize healthcare operations. however, as ai's role expands in medical education, discussions arise about balancing its benefits with cultivating hands-on clinical skills. this calls for an integrated approach that harmonizes ai-driven advancements with traditional curricula, ensuring that students gain both special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.94 dhr proceedings ǀ http://dhrproceedings.org 4 2023, vol. 3 no. s1 1--5 technical proficiency and practical expertise. challenges, including the presence of immature prototypes, varying evaluation methods, and ethical concerns, underscore the complexity of ai integration. to harness ai's full potential, effective integration strategies are crucial, equipping future medical practitioners with the proficiency needed to navigate the evolving healthcare landscape. within these challenges lies a transformative opportunity to redefine medical education, enhancing healthcare professionals’ capabilities and elevating patient care to new heights. as ai continues to evolve, the journey towards comprehensive ai integration in medical education is set to shape the future of healthcare. references 1. deshmukh r, rathi p. artificial intelligence in medicine. j assoc physicians india. 2022;70(3):11-12. 2. lu y. artificial intelligence: a survey on evolution, models, applications and future trends. journal of management analytics. 2019;6(1):1-29. https://doi.org/10.1080/23270012.2019.1570 365 3. lee d, yoon sn. application of artificial intelligence-based technologies in the healthcare industry: opportunities and challenges. international journal of environmental research and public health. 2021;18(1):271. doi:https://doi.org/10.3390/ijerph18010271 4. masters k. artificial intelligence in medical education. medical teacher. 2019;41(9):976-980. https://doi.org/10.1080/0142159x.2019.1595 557 5. han er, yeo s, kim mj, lee yh, park kh, roh h. medical education trends for future physicians in the era of advanced technology and artificial intelligence: an integrative review. bmc med educ. 2019;19(1):460. published 2019 dec 11. doi:10.1186/s12909019-1891-5 6. pappas m, drigas a. incorporation of artificial intelligence tutoring techniques in mathematics. international journal of engineering pedagogy (ijep). 2016;6(4):12. https://doi.org/10.3991/ijep.v6i4.6063 7. lillehaug si, lajoie sp. ai in medical education—another grand challenge for medical informatics. artificial intelligence in medicine.1998;12(3):197-225. https://doi.org/10.1016/s09333657(97)00054-7 8. paranjape k, schinkel m, nannan panday r, car j, nanayakkara p. introducing artificial intelligence training in medical education (preprint). jmir medical education. 2019;5(2). https://doi.org/10.2196/16048 9. chan ks, zary n. applications and challenges of implementing artificial intelligence in medical education: integrative review. jmir medical education.2019;5(1):e13930. https://doi.org/10.2196/13930 10. lee i, perret b. preparing high school teachers to integrate ai methods into stem classrooms. proceedings of the aaai conference on artificial intelligence. 2022;36(11):12783-12791. https://doi.org/10.1609/aaai.v36i11.21557 11. nagi f, salih r, alzubaidi m, et al. applications of artificial intelligence (ai) in medical education: a scoping review. studies in health technology and informatics. published online 2023. doi:10.3233/shti230581 12. kolachalama vb, garg ps. machine learning and medical education. npj digital medicine. 2018;1(1). https://doi.org/10.1038/s41746018-0061-1 13. goh ps, sandars j. a vision of the use of technology in medical education after the covid-19 pandemic. mededpublish. 2020;9(1). https://doi.org/10.15694/mep.2020.000049.1 14. hwang gj, xie h, wah b, gašević d. vision, challenges, roles and research issues of artificial intelligence in education. computers and education: artificial intelligence. 2020;1:100001. https://doi.org/10.1016/j.caeai.2020.100001 15. wartman sa. the empirical challenge of 21st century medical education. academic medicine. published online july 2019:1. https://doi.org/10.1097/acm.0000000000002 866 16. zhang w, cai m, lee hj, evans r, zhu c, ming c. ai in medical education: global situation, effects and challenges. education and information technologies. published online 2023. doi:10.1007/s10639-02312009-8 https://doi.org/10.1016/s0933-3657(97)00054-7 https://doi.org/10.1016/s0933-3657(97)00054-7 https://doi.org/10.2196/16048 https://doi.org/10.2196/13930 https://doi.org/10.1038/s41746-018-0061-1 https://doi.org/10.1038/s41746-018-0061-1 special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.94 dhr proceedings ǀ http://dhrproceedings.org 5 2023, vol. 3 no. s1 1--5 17. ngo b, nguyen d, vansonnenberg e. the cases for and against artificial intelligence in the medical school curriculum. radiol artif intell. 2022 aug 17;4(5):e220074. doi: 10.1148/ryai.220074. pmid: 36204540; pmcid: pmc9530767. 18. pashkov vm, harkusha ao, harkusha yo. artificial intelligence in medical practice: regulative issues and perspectives. wiad lek. 2020;73(12 cz 2):2722-2727. pmid: 33611272. 19. seth p, hueppchen na, miller sd, et al. data science as a core competency in undergraduate medical education in the age of ai in healthcare (preprint). jmir medical education. 2023;9:e46344-e46344. https://doi.org/10.2196/46344 20. grunhut j, wyatt at, marques o. educating future physicians in artificial intelligence (ai): an integrative review and proposed changes. journal of medical education and curricular development. 2021;8:238212052110368. https://doi.org/10.1177/23821205211036836 21. srivastava tk, waghmare l. implications of artificial intelligence (ai) on dynamics of medical education and care: a perspective. journal of clinical and diagnostic research. published online 2020. https://doi.org/10.7860/jcdr/2020/43293.135 65 22. feng s, shen y. chatgpt and the future of medical education. academic medicine. 2023;publish ahead of print. https://doi.org/10.1097/acm.0000000000005 242 23. ngo b, nguyen d, vansonnenberg e. artificial intelligence: has its time come for inclusion in medical school education? maybe…maybe not. mededpublish. 2021;10(1). https://doi.org/10.15694/mep.2021.000131.1 24. leimanis a, palkova k. ethical guidelines for artificial intelligence in healthcare from the sustainable development perspective. european journal of sustainable development. 2021;10(1):90. https://doi.org/10.14207/ejsd.2021.v10n1p9 0 special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.70 dhr proceedings ǀ http://dhrproceedings.org 100 2022, vol. 2 no. s2 100-105 commentary physiological effects of melatonin in children samantha lara1,2, danna hernandez1,2, jaime balli1,2, ruby villa1,3, saul martinez1,3, david saldana1,3, sandy poy aguilar1,3, krystian rodriguez1,4, clarissa garza1,4, gino martinez1,4, jessica cervantes1,4 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2progreso early college high school, progreso, tx 3los fresnos high school, los fresnos, tx 4la villa early college high school, la villa, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 08/04/2022 accepted for publication 08/15/2022 published 08/15/2022 melatonin overview melatonin is a hormone produced in the body that affects when a person sleeps [1]. it contains 16 hydrogen atoms, 13 carbon atoms, 2 nitrogen atoms, and 2 oxygen atoms (c13h16n2o2) [2]. the hormone gets produced in the pineal gland located in the brain. the hormone is then shot into the bloodstream [3]. depending on whether there is light (day) or darkness (night), the levels of melatonin increase and decrease [1]. sometimes, however, the melatonin levels at night can be low, making it difficult to fall asleep. this causes people to rely on a melatonin supplement that helps increase their melatonin levels. this supplement comes in various forms that can be bought over the counter. for instance, you can find them as forms of pills, drops, sprays, and gummies. in addition, you can either get this supplement natural or synthetic. however, the natural form is made in pineal glands from animals that can be contaminated by viruses during the extraction, while synthetic is manmade and does not carry the same risk. [4]. melatonin use melatonin is utilized by many different people for a variety of reasons. according to the cdc, a 10-year period study by the american association of poison control centers’ national poison data system reported that the yearly number of melatonin intake increased by 530% with 260,435 pediatric melatonin ingestions announced [5]. however, melatonin is not only utilized in children; it can also be prescribed and used by adults in order to aid in problems involving short-term sleep. moreover, in the united states, the purchase and intake of melatonin doubled between 20072012, making it the 4th most natural product consumed by adults and 2nd most natural product consumed by lara, et al melatonin in children https://doi.org/10.47488/dhrp.v2is2.70 dhr proceedings ǀ http://dhrproceedings.org 101 2022, vol. 2 no. s2 100-105 children [6]. melatonin’s popularity is continuously growing due to the fact that it can be used to regulate sleep cycles where the creation of melatonin is influenced by the specific time of day. melatonin supplements can also be utilized to help in withdrawal from benzodiazepines and in decrease of blood pressure [7]. in addition, there are even specific diseases that require melatonin use in order to help the individual who has acquired that disease. for instance, as stated by the mayo clinic, melatonin can be utilized to benefit and improve insomnia for older adults by decreasing the individual’s ability to fall asleep, regulating circadian rhythm sleep disorders in the blind in children and adults, and jet lag symptoms by enhancing attentiveness and tiredness during the day [1]. furthermore, melatonin is extremely effective and can even be used to improve and reduce the pain of a uterine disorder known as endometriosis in adults by taking melatonin orally [8]. melatonin prescriptions melatonin is prescribed by doctors to treat circadian rhythm disorders, and to provide relief for insomnia [9]. it may also be used to substitute the hormone for patients who are melatonin deficient throughout the night [10]. another reason that doctors may be prescribing it is to help with anxiety before or after surgery [9]. researchers have found that the prescribing of melatonin for hospitalized patients has increased substantially over a 4-year period, despite limited research on dosing, [11]. beneficial and adverse outcomes of melatonin use parents administer melatonin to children and/or teenagers to help them get to a more relaxed state before bed. however, melatonin is already naturally produced. although there is no real evidence of overdosing on melatonin, it is still a risk [12]. anytime a child ingests melatonin, they run the risk of experiencing certain side effects. for example, nausea, vomiting, headaches, hypotension or hypertension [12,13]. a long-term health risk from melatonin has not been found since there is a lack of high-quality studies in the u.s. however, increased use of melatonin at the pediatric stage can lead to multiple disorders [13]. for example, cardiac disorders, circadian rhythm, delay sexual maturation, and depression. although there are certain downfalls when using otc melatonin, there are also some positives. according to new research, melatonin has been shown to synchronize the circadian rhythms, and improve the onset, duration and quality of sleep [14]. every year the number of overdoses involved with melatonin have increased dramatically [9]. according to a study conducted, the number of reports to u.s. poison control centers about people 19 years and younger who took melatonin increased from 8,337 in 2012 to 52,563 in 2021 [9]. adverse effects of melatonin use pulmonary hypertension pulmonary hypertension in children is caused by congenital heart defects present at birth [16]. pulmonary hypertension is narrowed, blocked, or destroyed blood vessels in the heart which causes high blood pressure that affects arteries in the lungs and the right side of the heart while simultaneously causing blood clots, arrhythmia, and bleeding in the lungs [17]. it also inhibits the body’s natural production of melatonin. melatonin supplements are shown, in recent studies, to have lowered the severity of pulmonary hypertension, helping to prevent chronic hypoxia caused by pulmonary hypertension, and also have anti-inflammatory effects, which inhibits oxidative stress, restoring nitric oxide production. in a study conducted through 2014 2019, 64 adult patients, 43 patients diagnosed with pulmonary arterial hypertension and 21 patients diagnosed with chronic thromboembolic pulmonary hypertension, and 111 individuals who reported themselves as healthy were used to test the positive and negative effects of melatonin in their cardiovascular and respiratory health, under the accordance of the declaration of helsinki. consistent blood sampling was performed during each scheduled visit, between the times of 9:00 and 18:00, where the natural melatonin levels in the blood were expected to be stable. blood samples would then be frozen and stored in aliquots at -80c and then thawed only once for use. lara, et al melatonin in children https://doi.org/10.47488/dhrp.v2is2.70 dhr proceedings ǀ http://dhrproceedings.org 102 2022, vol. 2 no. s2 100-105 melatonin levels were measured using ultraperformance liquid chromatography-tandem mass spectrometry. the results obtained from these tests help show the difference in melatonin levels in the patients. overall, the research came to the conclusion that individuals who have been diagnosed with pah or cteph have an independent risk factor of pah in logistic regression analysis while individuals who have lower levels of melatonin were predicted to have a worse long-term survival rate [15]. valvular heart disease melatonin inhibits nf-kb/creb/ runx2 that stimulates and increases aortic valve calcification [18]. it causes a high mortality rate. (many deaths) this study showed that the use of melatonin signals valvular interstitial cell calcification of the aortic valve, leading to aortic valve disease. aortic calcification is a disease in which calcium deposits form on the aorta and most commonly the aortic valve. this causes narrowing also known as stenosis thus causes reduced blood flow, this poor blood perfusion and circulation that may often cause medical issues and increases the risk of death [19]. delay in sexual maturation melatonin may affect the length of one’s ovulation cycle and may affect menopause as well [20]. the use of long term melatonin (2 or more years) will delay one’s sexual maturity. long term use of melatonin delays sexual maturity by interrupting the decline in melatonin levels that occur at night and on the beginning of puberty [21]. there are many different studies that show the correlation in sexual maturation and melatonin use in adolescent individuals. in a recent research study animal studies showing the exogenous melatonin can suppress gnrh secretion [21]. gnrh secretion is responsible for sexual development, ovulation cycles, and regulating the onset of puberty. suppression of this hormone can produce pubertal disorders indicating this may affect a child’s sexual maturation [22]. interactions between melatonin and other medications and herbal remedies through research, the effects of melatonin along with other medications and herbal remedies are shown to increase the risk of situations to worsen. for example, anticoagulants, anti-platelet, and herbs are medicines used to reduce blood clotting. however, when these drugs combine with melatonin it could increase the risk of bleeding. furthermore, the use of melatonin along with blood pressure drugs and diabetes medications might affect blood pressure and sugar levels. as a result, the adverse effects melatonin has with medicine can lead to many problems [1]. current research melatonin can be used to help women, who have breast cancer, to help slow the growth of cancer cells. several studies have shown it can also increase the risk of side effects of chemotherapy drugs (that are used to help treat cancer) including loss of appetite, nausea, diarrhea, hair loss, a change in the muscles (muscle strain and loss of strength), nerve (numbness and pain in thumbs and toes), and hearing (loss in hearing), and increased risk of infections. however, melatonin can also have an opposite effect on medication [23]. although the use of melatonin can help benefit people with different problems like breast cancer, it could also interfere with medications causing them to either “cancel out” the medication or to make the medication more “powerful”. for instance, in type 2 diabetics, they take a medication called metformin that is used to help the body regulate blood sugar levels. (nhs) however, when people with type 2 diabetes take melatonin, the melatonin levels do increase, but the melatonin reduces the ability for the insulin to create more insulin causing it hard to regulate blood sugar levels. this results in the pancreas working harder to produce enough insulin for the glucose [25]. a different study shows that melatonin can have an effect on diabetes medications. in recent studies, melatonin has many effects on pancreatic b-cells (cells that release insulin that plays a key role in glucose regulation). non-functional pancreatic b-cells lead to uncontrolled blood glucose levels and diabetes. pancreatic b-cells are susceptible to oxidative stress which reduces the function or lara, et al melatonin in children https://doi.org/10.47488/dhrp.v2is2.70 dhr proceedings ǀ http://dhrproceedings.org 103 2022, vol. 2 no. s2 100-105 survival of b-cells. however, melatonin can provide protection against it and help balance the amount of insulin produced [24]. conclusion overall, melatonin is used to help children receive the recommended amount of sleep and provide parents with relief, however, numerous studies have shown that the use of melatonin in the pediatric population can carry cons such as causing unwanted side effects like nausea, loss of appetite, delay in sexual maturation, and worsening of chronic disease symptoms. on the contrary to the effects melatonin has with other medications, it is also shown to help improve various medicines to treat diseases. for example, the many research studies that have gone into finding a proper treatment for covid-19. as covid-19 has been on the watch list for many doctors, researchers have found vitamin c and d work efficient against covid-19. since, vitamin c helps the body with its healing process along with increasing the antioxidative (oxidative damages cells, proteins, and dna function, and vitamin d helps with the immune system. combining them with melatonin, vitamin c defense against oxidative and vitamin d immune systems improve [28]. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected and region one esc paths references 1. melatonin. (n.d.). mayo clinic. retrieved july 29, 2022, from https://www.mayoclinic.org/drugssupplements-melatonin/art-20363071 2. national center for biotechnology information (2022). pubchem compound summary for cid 896, melatonin. retrieved august 1, 2022 from https://pubchem.ncbi.nlm.nih.gov/compound /melatonin. 3. melatonin and sleep. (2022, april 8). sleep foundation. retrieved july 29, 2022, from https://www.sleepfoundation.org/melatonin 4. what is melatonin? can't sleep | familydoctor.org. (2000, september 1). familydoctor.org. retrieved august 1, 2022, from https://familydoctor.org/melatonin/ 5. lelak, k. (2022, june 2). pediatric melatonin ingestions — united states. . . centers for disease control and prevention, from https://www.cdc.gov/mmwr/volumes/71/wr/ mm7122a1.htm 6. grigg-damberger, m. m., & ianakieva, d. (2017). poor quality control of over-thecounter melatonin: what they say is often not what you get. journal of clinical sleep medicine: jcsm : official publication of the american academy of sleep medicine, 13(2), 163–165. https://doi.org/10.5664/jcsm.6434 7. encyclopædia britannica. (n.d.). melatonin. britannica academic. retrieved august 1, 2022, from https://academic-ebcom.ezproxy.southtexascollege.edu/levels/c ollegiate/article/melatonin/51873 8. melatonin: overview, uses, side effects, precautions, interactions, dosing and reviews. (2005). webmd. retrieved august 2, 2022, from https://www.webmd.com/vitamins/ai/ingredi entmono940/melatonin#:%7e:text=people%20most %20 commonly%20use%20 melatonin, support%20best%20of%20these%20 uses 9. melatonin: what you need to know. (n.d.). national center for complementary and integrative health. retrieved august 1, 2022, from https://www.nccih.nih.gov/health/melatoninwhat-you-need-to-know 10. hardeland r. (2012). neurobiology, pathophysiology, and treatment of melatonin deficiency and dysfunction. thescientificworldjournal, 2012, 640389. https://doi.org/10.1100/2012/640389 11. procaccini, d. e., & kudchadkar, s. r. (2021). melatonin administration patterns for pediatric inpatients in a tertiary children's hospital. hospital pediatrics, https://www.cdc.gov/mmwr/volumes/71/wr/mm7122a1.htm https://www.cdc.gov/mmwr/volumes/71/wr/mm7122a1.htm https://doi.org/10.5664/jcsm.6434 https://academic-eb-com.ezproxy.southtexascollege.edu/levels/collegiate/article/melatonin/51873 https://academic-eb-com.ezproxy.southtexascollege.edu/levels/collegiate/article/melatonin/51873 https://academic-eb-com.ezproxy.southtexascollege.edu/levels/collegiate/article/melatonin/51873 lara, et al melatonin in children https://doi.org/10.47488/dhrp.v2is2.70 dhr proceedings ǀ http://dhrproceedings.org 104 2022, vol. 2 no. s2 100-105 11(11), e308–e312. https://doi.org/10.1542/hpeds.2021-006117 12. what are the dangers of taking too much melatonin? (2022, april 12). verywell health. retrieved august 3, 2022, from https://www.verywellhealth.com/melatoninoverdose-5219376 13. https://www.mayoclinic.org/drugssupplements-melatonin/art20363071#:~:text=less%20 common%20 melatonin%20side%20effects,hours%20of% 20making%20the%20 supplement 14. xie, z., chen, f., li, w. a., geng, x., li, c., meng, x., feng, y., liu, w., & yu, f. (2017). a review of sleep disorders and melatonin. neurological research, 39(6), 559–565. https://doi.org/10.1080/01616412.2017.1315 864 15. cai, z., klein, t., geenen, l. w., tu, l., tian, s., van den bosch, a. e., de rijke, y. b., reiss, i., boersma, e., duncker, d. j., boomars, k. a., guignabert, c., & merkus, d. (2020). lower plasma melatonin levels predict worse long-term survival in pulmonary arterial hypertension. journal of clinical medicine, 9(5), 1248. https://doi.org/10.3390/jcm9051248 16. pulmonary hypertension in children. (n.d.). johns hopkins medicine. retrieved august 1, 2022, from https://www.hopkinsmedicine.org/health/co nditions-and-diseases/high-blood-pressurehypertension/pulmonary-hypertension-inchildren 17. pulmonary hypertension symptoms and causes. (2022, april 13). mayo clinic. retrieved august 1, 2022, from https://www.mayoclinic.org/diseasesconditions/pulmonaryhypertension/symptoms-causes/syc20350697 18. li sj, cheng wl, kao yh, chung cc, trang nn, chen yj. melatonin inhibits nfκb/creb/runx2 signaling and alleviates aortic valve calcification. front cardiovasc med. 2022 jun 20;9:885293. doi: 10. .2022.885293. pmid: 35795373; pmcid: pmc9251177 https://pubmed.ncbi.nlm.nih.gov/35795373/ 19. shah sy, higgins a, desai my. bicuspid aortic valve: basics and beyond. cleve clin j med. 2018 oct;85(10):779-784. doi: 10.3949/ccjm.85a.17069. pmid: 30289756. https://pubmed.ncbi.nlm.nih.gov/30289756 20. greendale, g. a., witt-enderby, p., karlamangla, a. s., munmun, f., crawford, s., huang, m., & santoro, n. (2020). melatonin patterns and levels during the human menstrual cycle and after menopause. journal of the endocrine society, 4(11), bvaa115. https://doi.org/10.1210/jendso/bvaa115 21. boafo, a., greenham, s., alenezi, s., robillard, r., pajer, k., tavakoli, p., & de koninck, j. (2019). <p>could long-term administration of melatonin to prepubertal children affect timing of puberty? a clinician&rsquo;s perspective</p> nature and science of sleep, volume 11, 1–10. https://doi.org/10.2147/nss.s181365 22. marques p, skorupskaite k, rozario ks, et al. physiology of gnrh and gonadotropin secretion. [updated 2022 jan 5]. in: feingold kr, anawalt b, boyce a, et al., editors. endotext [internet]. south dartmouth (ma): mdtext.com, inc.; 2000-. available from: https://www.ncbi.nlm.nih.gov/books/nbk2 79070/ 23. melatonin information. (n.d.). mount sinai. retrieved august 3, 2022, from https://www.mountsinai.org/healthlibrary/supplement/melatonin 24. espino, j., pariente, j. a., & rodríguez, a. b. (2011). role of melatonin on diabetes-related metabolic disorders. world journal of diabetes, 2(6), 82–91. https://doi.org/10.4239/wjd.v2.i6.82 25. garaulet, m., qian, j., florez, j. c., arendt, j., saxena, r., & scheer, f. (2020). melatonin effects on glucose metabolism: time to unlock the controversy. trends in endocrinology and metabolism: tem, 31(3), 192–204. https://doi.org/10.1016/j.tem.2019.11.011 26. type 2 diabetes understanding medicine. (n.d.). nhs. retrieved august 2, 2022, from https://www.nhs.uk/conditions/type-2diabetes/understanding-medication/ 27. gavin, m. l. (n.d.). what is type 2 diabetes? (for teens) nemours kidshealth. kids health. retrieved august 2, 2022, from https://kidshealth.org/en/teens/type2.html 28. does evidence exist to blunt inflammatory response by nutraceutical supplementation during covid-19 pandemic? an overview lara, et al melatonin in children https://doi.org/10.47488/dhrp.v2is2.70 dhr proceedings ǀ http://dhrproceedings.org 105 2022, vol. 2 no. s2 100-105 of systematic reviews of vitamin d, vitamin c, melatonin, and zinc. (2021, april 12). ncbi. retrieved august 3, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/p mc8069903/ special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.54 dhr proceedings ǀ http://dhrproceedings.org 55 2022, vol. 2 no. s2 55-60 commentary what are the common risk factors of obesity in children? sandra perez1,3, judith zarate1,2, sheyla gonzalez1,2, michelle hernandez1,3, melanie antonio1,3, stacy villegas1,2, viviana rincon1,3, ligia gutierrez1,2, monica hernandez1,3, monica ramirez1,3 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2dr. leo g cigarroa high school, laredo, tx 3donna north high school, donna, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 06/30/2022 accepted for publication 08/05/2022 published 08/05/2022 keywords: obesity; children; cdc: centers for disease control and prevention introduction today, obesity is a prevalent problem in the united states not only in adults but unfortunately, also affecting our children. obesity is a disease involving an excessive amount of body fat. obesity increases the risk of other diseases that could be more dangerous for example heart diseases, diabetes, high blood pressure, and certain cancers. many children, regrettably, get these diseases at a very young age. according to the cdc, “obesity among children and adolescents is still too high” [1]. in a study done from 2017-2020, about 14 million children from ages 9-12 suffered from obesity in the united states. childhood obesity in the united states mostly affects hispanic and african american children more than any other ethnic group. hispanic children have a higher percentage of obesity than african american children with 26.2% and african american being 24.8%. we will look at the risk factors, diseases and possible management of this growing problem with our children and look at possible solutions [1]. risk factors diet fast foods are foods that are usually prepared quickly in restaurants or at home. with a busy society, quick meals sometimes are a choice for many american families. fast foods may come full in saturated fat, sodium, preservatives and calories. children love to consume fast food because of all these things they have available. children don't know what they are consuming, what they know is the food is very tasteful. the percentage of children with obesity increased. in a survey organized by cse, 13,274 children reported that 93% ate packaged food and 68% consumed packaged sweetened beverages more than once a week, 53% ate these products once a day [2]. children consume food with high levels of sugar, salt, and fat from fast foods more than once a week. obesity has more than doubled in children since 2017 [2]. doctors saw that fast food intake was categorized as more than 4 times per week. ever since covid19 started, the percentages in obesity not just perez, et al. obesity in children https://doi.org/10.47488/dhrp.v2is2.54 dhr proceedings ǀ http://dhrproceedings.org 56 2022, vol. 2 no. s2 55-60 for children but for everyone else increased. covid19 had an impact on obesity when children started to consume fast food due to the compromise of immunity in the individuals and further exacerbating organ damage [2]. since covid-19 was really scary, people wouldn’t go out as much to buy groceries [2]. fast food was an accessible option most of the time. in the hispanic culture, when we find food at the house or anywhere, we end up eating it. especially children, there could be candies, chips, chocolates, sweet stuff, etc., and kids will eat it. obesity changed once the percentages raised due to fast foods. effect of school diet on obesity the benefits of school food are various. it offers beneficial nutrients. however, children don’t eat it because they don't like the way it tastes or looks. students start eating junk food they buy either at school or at the shop if they don't eat the school lunch. obesity is a national epidemic in which 1 in 3 children are at risk for preventable diseases like diabetes and heart disease due to obesity. school meals are trying to help children learn how to have a healthy lifestyle [3]. the healthy, hunger free kids act of 2010 are in charge of the changes for the school meals [3]. the new school meals are deliberately high in nutrients and low on calories. these meals have to be consistent with nutrition science, the new portion sizes and calorie ranges reflect the latest scientific recommendations. based on their age, students are getting recommended portions. schools are providing more vegetables and fruits [3]. school food may not be causing obesity, but it is the reason why children choose junk food over the food from lunch which leads to obesity. students skip their meals and eat junk food sold in vending machines or at school. one way we can avoid this is to research what students from different backgrounds like and take out vending machines from schools. portion control children can maintain a healthy weight by learning healthy eating habits from their parents, guardians, and teachers. according to research, when presented with larger servings, consumers unintentionally consume more calories. reduce the availability of salty, high-fat, and high-sugar snacks for your kids to help them establish healthy eating habits [4]. utilizing calorie counters can help you lose, maintain, or gain weight. the right number of calories should be consumed along with a well-balanced diet. food labels should be properly read and understood to ensure that calories are consumed along with unsaturated fats, complex carbs, low salt, vitamins, and proteins. when cutting calories to lose weight, you need to be cautious. lack of nutrients could arise from drastically reducing calories. a person must burn off 3500 calories in order to shed one pound (lb) of weight [18]. by increasing physical activity and lowering daily caloric intake, this can be achieved. losing more than 2 pounds (lb) of weight per week is not advised in order to maintain a sufficient intake of nutrients [5]. for more information: (how to avoid portion size pitfalls additionally, it's essential to drink enough water each day for your health. dehydration can be averted by drinking water. when water is exchanged for beverages with calories, body weight can be controlled, and calorie intake can be decreased. added sugars provide calories but no important nutrients to your diet. as a result, they cannot be utilized to increase muscle mass, give vitamins, encourage a feeling of fullness, or offer any other nutritional advantages. diseases diabetes type 2 a diet that contains too much sugar can cause type 2 diabetes, heart disease, weight gain, and obesity 4]. type 2 diabetes affects 90–95% of patients with diabetes [6]. your body struggles to properly utilize insulin in type 2 diabetes, making it difficult to maintain normal blood sugar levels [6]. carbohydrates, lipids and proteins break down into glucose which serve as a primary source of energy in our bodies releasing it into our bloodstream [6]. our bodies require energy in the form of atp for a variety of processes, such as metabolism, respiration, excretion, and exercise. our systems control the surplus glucose by storing it as glycogen in the liver, releasing the hormone insulin from the pancreas to control blood sugar levels, and cleansing the blood of extra waste materials, including glucose, through the kidney. diabetes is brought on by an overabundance of glucose in the liver, which harms the pancreas' https://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/portion_size_pitfalls.pdf https://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/portion_size_pitfalls.pdf perez, et al. obesity in children https://doi.org/10.47488/dhrp.v2is2.54 dhr proceedings ǀ http://dhrproceedings.org 57 2022, vol. 2 no. s2 55-60 declining ability to secrete insulin. kidneys are then challenged to remove waste from blood. skin conditions like acanthosis nigrican can cause black patches to develop in body crevices like your neck, armpits, groin, hands, elbows, or knees. this may be a symptom of insulin resistance and could indicate type 2 diabetes. heart disease according to statistics from 1976 to 1980, 6.5 percent of children aged 6 to 11 were obese; by 1980, the number had risen to 17 percent [7]. nearly 9,000 kids and teenagers ages 3 to 19 who were overweight or obese participated in this study “cardiometabolic risks and severity of obesity in children and young adults”. doctors checked these young people for diabetes, high blood pressure, high cholesterol, and other critical heart disease risk factors. type 2 diabetes, high blood pressure, and high cholesterol are just a few of the heart disease risk factors that are brought on by childhood obesity and were originally believed to be “adult” health issues. the earlier heart disease and stroke develop, the earlier childhood obesity manifests itself. you can lose more weight if you exercise, eat a balanced diet high in protein but low in fat, and estimate your servings so that they are appropriate. hyperlipidemia in obese children hyperlipidemia has become a common condition amongst obese children [8]. this condition conveys there are abnormal levels of lipids, or fats circulating in the blood. since high cholesterol has no symptoms, many people are unaware that their cholesterol levels are unhealthy. however, a quick blood test can detect high cholesterol. hyperlipidemia can be caused by consumption of food or genetics in which cholesterol is produced in your body naturally. one of the main risk factors is a person’s diet which can lead to obesity and later on to hyperlipidemia, narrowing the arteries and blocking the flow of blood. processed foods and foods high in saturated and trans fats are the main causes of obesity in children, being overweight or obese raises the chances of developing hyperlipidemia because there is a higher likelihood to have increased levels of fat tissue. seven percent of u.s children and adolescents ages 6 to19 have high cholesterol (hyperlipidemia) [8]. children are more obese today than in previous times due to the high consumption of fats. thus, obesity in childhood is considered one of the major critical public health problems. based on a study conducted on body size and other factors the prevalence of obesity and the association between obesity and hyperlipidemia amongst the children was demonstrated [9]. peripheral artery disease a composition of saturated fats may cause peripheral artery disease, narrowing arteries including blood flow to arms and legs[10]. arteries narrow due to accumulation of fatty deposits in aleurites caltheos (crosis) reducing blood flow. peripheral nerves are very fragile and easy to damage. a nerve injury can cause loss of communication with muscles and organs. the treatment for peripheral artery disease includes maintaining a healthy lifestyle, with a healthy diet, exercise, and sometimes even medications. medications may be needed to reduce cholesterol, high blood pressure, regulate glucose, prevent colds, and pain medication. management prevention among children the overweight and obesity epidemic among children and adolescents in the united states has worsened over the years. there are many ways that parents can help children. for example, take your children to get a bmi, or a body mass index measure, to get an idea as to what you can start doing to prevent obesity or other diseases. bmi is determined by a person's weight status. “it is calculated by dividing a person’s weight in kilograms by the square of height in meters” [11]. in children, bmi is age and gender specific. “children who spend more time indoors using social media, playing videos games, or watching television all day are most likely to become obese and later develop diabetes” [12]. on the internet, children come across advertisements of fast-food restaurants or junk food and as a result children cave to their cravings with whatever food they find. it is crucial to reduce your child’s screen time for 1 or 2 hours daily [13]. make sure your child gets 60 minutes of physical activities daily [14]. many children at night get up and eat food they are not supposed to therefore making them gain weight. sleeping adequately is important for children because it helps the child’s immune system and reduces the risk of obesity. they should at least be sleeping for 9 to 12 hours daily. perez, et al. obesity in children https://doi.org/10.47488/dhrp.v2is2.54 dhr proceedings ǀ http://dhrproceedings.org 58 2022, vol. 2 no. s2 55-60 changing the eating habits for the whole family is crucial because you are showing support to your child which will motivate them to change their diet. encourage your child and the whole family to start eating enough fruits, vegetables, whole grains, and a low or fat free diary. teach your child to only eat when they are hungry and to eat slowly. don’t use food as a reward or withhold food as a punishment. instead of giving your child beverages like juices and sodas, give them water or drinks with no added sugars. it is very important to stock the pantries with healthy food. education will help children overcome this obesity epidemic. education according to aafp [15], obesity was not thoroughly examined until recent years. children and adolescents need education about obesity since approximately 20% of american children are obese [1]. everyone, from medical professionals to parents and health departments, should be providing health education. physicians should advise parents to feed their children better, healthier meals and to get them moving by taking them on walks, taking them to the park, getting them involved in sports, or even jogging. they should begin by eating a balanced diet and getting enough calories. researchers have found that exercise is helpful for weight loss and maintaining weight loss. exercise can increase the number of calories you burn in a day. it can also help you maintain and increase lean body mass, which also helps increase the number of calories you burn within your body [15]. making healthy living choices should be a factor in learning, which involves introducing children to healthier foods early on and avoiding giving them drinks, sweets, or snacks as rewards [16]. this will help us avoid or lower the danger of diseases brought on by fat. as for community leaders, they should outreach other communities to educate the public, as well as making systemic changes in our society [17]. treatment options typically, advertisements for weight loss drugs target adults. it has not been established that diet supplements are safe for children due to lack of adequate research or testing. the alternative for children is diet and exercise [18]. once an obese individual contracts an illness. the remainder of their lives may require them to take prescribed medication. to regulate glucose levels in conditions like diabetes, doctors may give metformin and insulin. metformin reduces intestinal glucose absorption, hepatic glucose release, and increases insulin sensitivity [19] insulin facilitates blood sugar uptake by cells in the body. when blood sugar enters cells, blood sugar levels fall, which tells insulin to do the same [19]. lisinopril and benazepril are two examples of heart disease drugs that may be administered to treat or prevent heart attacks and cardiac arrest [20]. lisinopril lessens high blood pressure to help prevent strokes, heart attacks, and kidney problems. additionally, it helps patients survive longer after a heart attack and treats heart failure [20]. benazepril is used to treat hypertension. the workload on the heart and arteries is increased by high blood pressure. the heart and arteries may not work correctly if it occurs for a long time [20]. the term "hyperlipidemia" denotes abnormally high quantities of lipids, or fats, in the blood. hyperlipidemia can be treated with clofibrate. blood triglyceride and cholesterol levels are reduced with the use of clofibrate. this may aid in preventing health issues brought on by such things clogging blood vessels [20]. statins, a class of medications, are frequently used for peripheral artery disease. a class of medications known as statins has been shown to reduce blood levels of low-density lipoprotein cholesterol. statins aid in lowering bad cholesterol and preventing the buildup of arterial plaque. the medications also reduce the risk of stroke and heart attacks [20]. surgery from time to time, children come to the clinic with serious problems. at times, pediatricians and parents consider obesity surgery when children are in poor health. bariatric surgery is surgery that helps you lose weight by reducing the size of your stomach and making other changes to your digestive system [21]. this surgery helps solve health problems such as diabetes and high blood pressure. if the young patient decides to go forward with the bariatric surgery, they perez, et al. obesity in children https://doi.org/10.47488/dhrp.v2is2.54 dhr proceedings ǀ http://dhrproceedings.org 59 2022, vol. 2 no. s2 55-60 should consume enough food and liquids beforehand. children should not be untreated or poorly managed before or after surgery. obesity surgery is generally well tolerated and minimizes the risk of serious perioperative complications. the most common mild complications were postoperative wound and urinary tract infections [21]. on the other hand, 95% showed remission of type 2 diabetes 3 years after surgery [21]. conclusion an excessive quantity of body fat is a symptom of the disease known as obesity, which raises the chance of developing additional illnesses. unfortunately, a lot of people develop these illnesses at a young age. preventing childhood obesity is more cost-effective than treating it. only a small number of medications are approved for use as treatments, and even then only under strict monitoring. there may be medication available now to treat these disorders, but that does not guarantee a cure. medication only controls the issues. it is up to us to aid in the eradication of diseases or stop it from beginning. it is important to acknowledge that obesity is a family disease affected by multiple factors, such as genetics, the environment, food intake, and physical activity. many of the environmental factors that contribute to childhood obesity can be changed or corrected. increased awareness and continued family support should be prioritized in order to change the person's behavior. in actuality, adopting a far healthier lifestyle would be a superior option for avoiding all those hazards. society should focus on education and reducing the stigma associated with obesity. mental health is also an important factor in maintaining a healthy lifestyle. having good health is significant since it refers to the state of being physically, mentally, and socially healthy. acknowledgements dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. cdc. (2021, april 5). childhood obesity facts. cdc. https://www.cdc.gov/obesity/data/childhood. html 2. junk food-induced obesitya growing threat to youngsters during the pandemic.obes med. 2021 sep; 26: 100364.https://www.ncbi.nlm.nih.gov/pmc/a rticles/pmc8459649/ 3. the school day just got healthier | food and nutrition service. (n.d.). www.fns.usda.gov. retrieved june 29, 2022, from https://www.fns.usda.gov/cn/school-dayjust-got-healthier-toolkit 4. md, n. m. (2015, september 30). overweight children are at risk for heart disease as adults. harvard health blog. https://www.health.harvard.edu/blog/overwe ight-children-are-at-risk-for-heart-diseaseas-adults-201509308367 5. cdc. (2018, july 18). tips for parents–ideas to help children maintain a healthy weight. centers for disease control and prevention. https://www.cdc.gov/healthyweight/children / 6. centers for disease control and prevention. (2021, december 16). type 2 diabetes. cdc. https://www.cdc.gov/diabetes/basics/type2.h tml 7. doheny, k. (n.d.). childhood obesity can lead to heart disease. webmd. https://www.webmd.com/children/features/c hildren-and-heart-disease-whats-wrongwith-this-picture 8. cdc. (2019, february 6). high cholesterol facts. centers for disease control and prevention. https://www.cdc.gov/cholesterol/facts.htm 9. lai, s. w., ng, k. c., lin, h. f., & chen, h. l. (2001). association between obesity and hyperlipidemia among children. the yale journal of biology and medicine, 74(4), 205– 210.https://www.ncbi.nlm.nih.gov/pmc/artic les/pmc2588770/pdf/yjbm00013-0005.pdf mayo clinic. (2021, january 14). peripheral artery disease (pad) symptoms and causes. mayo clinic. https://www.mayoclinic.org/diseaseshttps://www.cdc.gov/obesity/data/childhood.html https://www.cdc.gov/obesity/data/childhood.html https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8459649/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8459649/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8459649/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8459649/ https://www.fns.usda.gov/cn/school-day-just-got-healthier-toolkit https://www.fns.usda.gov/cn/school-day-just-got-healthier-toolkit https://www.health.harvard.edu/blog/overweight-children-are-at-risk-for-heart-disease-as-adults-201509308367 https://www.health.harvard.edu/blog/overweight-children-are-at-risk-for-heart-disease-as-adults-201509308367 https://www.health.harvard.edu/blog/overweight-children-are-at-risk-for-heart-disease-as-adults-201509308367 https://www.cdc.gov/healthyweight/children/ https://www.cdc.gov/healthyweight/children/ https://www.cdc.gov/diabetes/basics/type2.html https://www.cdc.gov/diabetes/basics/type2.html https://www.webmd.com/children/features/children-and-heart-disease-whats-wrong-with-this-picture https://www.webmd.com/children/features/children-and-heart-disease-whats-wrong-with-this-picture https://www.webmd.com/children/features/children-and-heart-disease-whats-wrong-with-this-picture https://www.cdc.gov/cholesterol/facts.htm https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2588770/pdf/yjbm00013-0005.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2588770/pdf/yjbm00013-0005.pdf https://www.mayoclinic.org/diseases-%0cconditions/peripheral-artery-disease/symptoms-causes/syc-20350557 perez, et al. obesity in children https://doi.org/10.47488/dhrp.v2is2.54 dhr proceedings ǀ http://dhrproceedings.org 60 2022, vol. 2 no. s2 55-60 conditions/peripheral-arterydisease/symptoms-causes/syc-20350557 11. cdc. (2021, december 3). bmi for children and teens. centers for disease control and prevention. https://www.cdc.gov/obesity/basics/childhoo d-defining.html 12. robinson, t. n., banda, j. a., hale, l., lu, a. s., fleming-milici, f., calvert, s. l., & wartella, e. (2017). screen media exposure and obesity in children and adolescents. pediatrics, 140(suppl 2), s97–s101. https://doi.org/10.1542/peds.2016-1758k 13. 6 tips to reduce children’s screen time. (n.d.). mayo clinic health system. retrieved june 30, 2022, from https://www.mayoclinichealthsystem.org/ho metown-health/speaking-of-health/6-tips-toreduce-childrens-screentime#:~:text=no%20screen%20time%20for %20children 14. cdc. (2019). youth physical activity guidelines. centers for disease control and prevention. https://www.cdc.gov/healthyschools/physica lactivity/guidelines.htm 15. department of health. (2007). preventing childhood obesity: tips for parents. ny.gov. https://www.health.ny.gov/prevention/nutriti on/resources/obparnts.htm 16. kerr, m. (2012). exercise and weight loss: importance, benefits & examples. healthline. https://www.healthline.com/health/exerciseand-weight-loss 17. 2021 report: from crisis to opportunity. (n.d.). the state of childhood obesity. https://stateofchildhoodobesity.org/2021repo rt/ 18. christens, b. d., inzeo, p. t., meinen, a., hilgendorf, a. e., berns, r., korth, a., pollard, e., mccall, a., adams, a., & stedman, j. (2016). community-led collaborative action to prevent obesity. wmj: official publication of the state medical society of wisconsin, 115(5), 259– 263. 19. rogovik, a. l., & goldman, r. d. (2009). should weight-loss supplements be ushttps://www.ncbi.nlm.nih.gov/pmc/article s/pmc4949920 20. table of medications:: diabetes education online. (n.d.). table of medications :: diabetes education online 21. .md, c. m. (2019, december 13). weight loss surgery for children and teens struggling with obesity. harvard health. https://www.he alth.harvard.edu/blog/weight-loss-surgeryfor-children-and-teens-struggling-withobesity2019121318478#:~:text=according%20to% 20the%20american%20academy https://www.mayoclinic.org/diseases-%0cconditions/peripheral-artery-disease/symptoms-causes/syc-20350557 https://www.mayoclinic.org/diseases-%0cconditions/peripheral-artery-disease/symptoms-causes/syc-20350557 https://www.cdc.gov/obesity/basics/childhood-defining.html https://www.cdc.gov/obesity/basics/childhood-defining.html https://doi.org/10.1542/peds.2016-1758k https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/6-tips-to-reduce-childrens-screen-time#:~:text=no%20screen%20time%20for%20children https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/6-tips-to-reduce-childrens-screen-time#:~:text=no%20screen%20time%20for%20children https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/6-tips-to-reduce-childrens-screen-time#:~:text=no%20screen%20time%20for%20children https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/6-tips-to-reduce-childrens-screen-time#:~:text=no%20screen%20time%20for%20children https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/6-tips-to-reduce-childrens-screen-time#:~:text=no%20screen%20time%20for%20children https://www.cdc.gov/healthyschools/physicalactivity/guidelines.htm https://www.cdc.gov/healthyschools/physicalactivity/guidelines.htm https://www.health.ny.gov/prevention/nutrition/resources/obparnts.htm https://www.health.ny.gov/prevention/nutrition/resources/obparnts.htm https://www.healthline.com/health/exercise-and-weight-loss https://www.healthline.com/health/exercise-and-weight-loss https://stateofchildhoodobesity.org/2021report/ https://stateofchildhoodobesity.org/2021report/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4949920 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4949920 https://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-non-insulin-therapies/table-of-medications/ https://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-non-insulin-therapies/table-of-medications/ https://www.health.harvard.edu/blog/weight-loss-surgery-for-children-and-teens-struggling-with-obesity-2019121318478#:~:text=according%20to%20the%20american%20academy https://www.health.harvard.edu/blog/weight-loss-surgery-for-children-and-teens-struggling-with-obesity-2019121318478#:~:text=according%20to%20the%20american%20academy https://www.health.harvard.edu/blog/weight-loss-surgery-for-children-and-teens-struggling-with-obesity-2019121318478#:~:text=according%20to%20the%20american%20academy https://www.health.harvard.edu/blog/weight-loss-surgery-for-children-and-teens-struggling-with-obesity-2019121318478#:~:text=according%20to%20the%20american%20academy https://www.health.harvard.edu/blog/weight-loss-surgery-for-children-and-teens-struggling-with-obesity-2019121318478#:~:text=according%20to%20the%20american%20academy https://www.health.harvard.edu/blog/weight-loss-surgery-for-children-and-teens-struggling-with-obesity-2019121318478#:~:text=according%20to%20the%20american%20academy special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.89 dhr proceedings ǀ http://dhrproceedings.org 45 2023, vol. 2 no. s2 45-50 commentary the effects of teenage pregnancy on maternal mental health isabella bechtold1,2, gouri menon1,2, helena solis1,2, jesus perez1,3, sarai rios1,3, jaclyn rodriguez1,3, lorenzo rubio1,3, leslie salgado1,3, emily paz1,4, laura ramirez1,4, angelina trevino1,4, siya vinoj1,5, debora santoyo rustrian1,5 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 mcallen memorial high school, mcallen, tx 3 edinburg high school, edinburg, tx 4 raymondville high school, raymondville, tx 5 mathematics and science academy, edinburg, tx received: august 3, 2023 accepted for publication: november 3, 2023 published: november 16, 2023 introduction teen pregnancy can have long lasting effects on a person's mental health, even after the child is born.1 approximately 16 million teenage girls ages 15-19 years old, and 2 million girls younger than 15 years old get pregnant each year around the world.2 teenage mothers are at increased risk for adverse social outcomes and short-term health problems, but longterm impacts on mental health are poorly understood. it has been stated that psychological distress and suicidal behaviors affect 13.3% to 20% percent of adolescent pregnant females.3 this goes to show that mental health can be very dangerous mentally, emotionally, and physically.4 whether these pregnancies are planned or unplanned, this age group of females have long-term implications. adolescent mothers and their children are exposed to multiple psychosocial risk factors and represent a high-risk group for adverse developmental outcomes.5 background information mental health is the state of being emotionally and mentally healthy, which is demonstrated by the lack of mental disease and by appropriate adjustment, particularly as shown by emotions of self-confidence, positive attitudes toward others, and the capacity to handle day-to-day tasks.6 from 2011 to 2021, female teens who experienced mental health challenges increased from 36 % to an astounding 57%.7 teenagers experience changes in the social, emotional, and cognitive aspect.8 female teens reported challenges that pertained to lgtbq, suicidal attempts, and sexual violence.7 among these many mental health challenges, teen pregnancy can greatly affect those who do not have a reliable support system. mental disorders are common in adolescence with one in four teenagers suffering from a disorder, according to national comorbidity data.9 furthermore, low economic status can affect the development of any mental disorder leading them to be at a higher risk.9 moreover, those who live in a less ideal environment, could have negative outcomes on pregnant adolescent women throughout their pregnancy journey. they are most likely to gain stress and anxiety due to frequent crime and trauma occurrence.9 teen pregnancy can be defined as anyone from 13 years of age to 20 years of age who becomes pregnant.10 in addition, teenage pregnancy has declined in recent years due to encouragement of contraception use and less teenagers engaging in sexual intercourse.10 teen pregnancy greatly attributes to decline in mental health and can severely affect teenage pregnant girls. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.89 dhr proceedings ǀ http://dhrproceedings.org 46 2023, vol. 2 no. s2 45-50 adaptations: neurobiological and cognitive neurobiological two pivotal stages of a young woman’s life are adolescence and pregnancy. while adolescent females are going through puberty and transitioning to adulthood, pregnant women are preparing for childbirth by supporting the development of the fetus. despite limited research over the neurobiological changes during teenage pregnancy, some studies suggest that adolescence and pregnancy share a similarity in that an increase in sex steroid hormones can lead to structural and functional changes in the brain.11 for instance, the age at which the volume and thickness of cortical gray matter is reduced closely relates to gonadarche, the pubertal onset of secondary sexual characteristics.12 various studies have used structural magnetic resonance imaging (mri) to view the gray and white matter components of the adolescent brain. as shown in figure 1, gray matter volume growth peaks in adolescence and decreases in adulthood with the strengthening of neuronal communication beginning to form within the prefrontal cortex region.13 figure 1. from 5 to 20 years: gray matter volume development over the prefrontal cortex.14 the prefrontal cortex is essential for complex behavioral performance, as this region of the brain is logical and precise.14 working alongside the limbic system, which is responsible for emotion and impulse, these processes work together to allow for a greater cognition.15 in figure 2, the limbic system matures earlier than the prefrontal cortex, allowing it to form a steeper curve than the prefrontal cortex.14 this graph demonstrates the gap between these two regions is greatest during adolescence as one system is fleshed out while the other is still developing. as a result, there is an imbalance of hormones as there is a bias towards emotional responses over rational decision making.14 hence, since the prefrontal cortex is the last to mature, the adolescent brain is in a vulnerable state to risky behaviors such as environmental stress, unprotected sex, and unplanned pregnancies.16 figure 2. a neurobiological model of adolescence: prefrontal cortex and subcortical limbic region development.14 in the postpartum phase of pregnancy, adolescent mothers experience significantly higher rates of depression than adult mothers and their nonpregnant peers.17 due to the dramatic rise and drop in progesterone and estrogen levels to support fetal development, these hormones have modulated areas of the brain, such as the amygdala, which are responsible for emotional regulation.18 therefore, behaviors that are exhibited during the pregnancy including mood swings and prolonged anger appear to have a longer duration, even when the hormones have leveled out in the body.12 thus, it is vital to consider the neurobiological adaptations adolescents experience prior and during pregnancy in order to understand the underlying mechanisms of depressive symptoms that may be disregarded. cognitive during pregnancy, some women may experience cognitive changes, usually referred to as “pregnancy brain”.19 symptoms that are related to this include periods of forgetfulness as well as memory disturbances.19 according to studies, hormonal effects have a great impact on cognitive functions.20 a teenager special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.89 dhr proceedings ǀ http://dhrproceedings.org 47 2023, vol. 2 no. s2 45-50 already experiences many cognitive changes, considering that their mind and body is still readily developing.21 therefore, impulsive and risky behaviors are common among this age group. during this time period, a transition from literal thinking to processing and operating occurs.21 due to this, pregnancy may affect the teen negatively, hindering the capability to meet physiological needs of pregnancy.22 when speaking of decreased cognitive ability, not only is the mother at risk, but the child as well. a study proved that children of teenage mothers (ages 18 and younger), had a significantly lower cognitive score than those whose mothers were aged 23-34 years. there was a clear and notable difference in scores for verbal, non-verbal, and spatial ability.23 changes in mental health through the pregnancy prenatal the term perinatal depression describes a type of disorder that occurs during pregnancy and after child birth perinatal depression is linked to changes in reproductive hormones, stress hormones, neurosteroid hormones (chemical compound).24 during the perinatal stage”, a mother prepares her body for the development of the fetus. vitamin d and omega-3, and well as maintain a good diet that includes good fatty acids, iron, and probiotics.25 approximately 26% of mental disorders are fundamentally linked to a number of physical health conditions; these actions would also reduce inequalities. furthermore, pregnant teens still attending school can experience school troubles, bullying from fellow classmates, and family issues “which “can also contribute to trauma which results in a decline of their results in a decline in their “mental health.”. these issues cannot only affect the mother but the newborn as well 38% mothers experience stress during pregnancy, which later lead to infant infections and complications.26 postnatal the postnatal period is a time of immense physical and emotional changes for teen mothers, influenced by hormonal fluctuations and the challenges of motherhood at such a young age. understanding the various mental health conditions that can arise during this time, such as postpartum depression, postpartum anxiety, and ptsd is crucial for healthcare professionals and caregivers to provide appropriate support and interventions.27 most adolescent pregnancies live a complex life, having to be a student and being a mother which can deeply affect their mental health in education and their future. changes in mental health symptoms throughout pregnancy and postnatal may have an impact on a teen woman's experience during a critical period. in spite of that, few studies have investigated these changes throughout the perinatal and postnatal period, notably changes in post-traumatic stress disorder (ptsd).27 ptsd is known as a mental disorder that emerges in response to a traumatic event that happened in an individual’s life. to better grasp an understanding of the role of ptsd in postnatal health, a study looked at the association between ptsd and associated postnatal behavioral risk factors to gain a better understanding of the impact of ptsd in postnatal health.28 ptsd and subclinical ptsd during the postpartum period were linked to behavioral health concerns, with ptsd at the start of pregnancy becoming a three-fold predictor of postpartum ptsd. women with ptsd and subclinical ptsd were more inclined to suffer stress (73%), anxiety (64%), and depression (73%), compared to those without ptsd, during the postpartum period.28 regardless of race or ptsd status, one out of every four women in the sample experienced a probable mental health issue or risk behavior during the postpartum period. given the prevalence of mental health risk factors associated with ptsd, these results call for more investigation into the changes of ptsd symptomatology through each pregnancy trimester to assess its role as a potential mediator during the perinatal period.28 abortion and ptsd the termination of a pregnancy, also known as an abortion, can contribute as a risk factor for mental illness in young mothers, with ptsd being one of the many. furthermore, long term ptsd has shown to have more of a psychological effect on young mothers who go forward with abortions rather than women who do not, which justifies the psychological impact that abortions cause to maternally young women. 29 however, there is no evidence that abortion necessarily causes ptsd, there is evidence that it may be an influence, given the fact that going through with the procedure can mentally scar a young woman.29 an abundance of guilt post-abortion can be a contributing factor to the ptsd that maternally young women experience, although this pertains to personal beliefs or values relating to abortion.30 studies have shown that abortions are higher in teen mothers, which relates to the fact that abortions are having a mental effect on young mothers. abortions not always being a choice, can also be a contributing factor to ptsd, young special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.89 dhr proceedings ǀ http://dhrproceedings.org 48 2023, vol. 2 no. s2 45-50 mothers are often forced into abortion due to being shunned by society and/or family which can lead to guilt and trauma.29 available resources and support pregnancy is the number one reason for high school dropouts; only 50% of teen mothers receive a high school diploma before the age of 22.31 the majority of these women leave school due to the lack of support that they had both inside and outside of school.32 this section outlines preventative strategies, coping mechanisms, and post-natal education for teen mothers. preventative methods “fewer than half of american women have been taught about contraceptives”.33 that leaves a big gap of women who are uneducated or unaware of types of contraceptives. abstinence is something to teach and encourage, for it is one hundred percent effective and can help slow down the start of teenagers being sexually active.34 as for teens who are sexually active, contraceptives are an effective way to lower the risk of pregnancy such as: condoms, iud, oral pills, and barrier methods. it is important to make an effort that involves the family, health providers, community, and school to prevent unintended pregnancies. as a parent or family member, it is beneficial to be active in a teen's social life and be aware that as they develop, they are likely to engage in sexual activities. they can use this as a time to educate and enforce the practice of contraceptives. health care providers can inform the teen patients on reproductive health services that they offer.35 pamphlets, infographics, and services available to educate the community on preventing teen pregnancy are essential. a good source that provides people an array of preventative health services and family planning is a website called the title x family planning clinic locator.35 as a community, there should be programs with a wide range of teachings including contraceptive methods. now, most schools provide teachings on an extensive sex education curriculum that has shown to reduce teenage pregnancy rates by 3 percent. however, teenagers can still be inconsistent or choose not to use contraceptives, which can lead to unintended pregnancies. this can lead to the question whether they are going to keep the baby, put it up for adoption, or have the fetus aborted. opportunities for teenage mothers once a teenager has made the decision to take the baby to full term, there are many things the mother needs to consider. these can range from healthcare options during the pregnancy to educational options after. there are many options to consider in terms of healthcare for teenage mothers. there are options for teenagers who need help to handle the psychological side of teenage pregnancy, programs for teenagers whose pregnancy was the result of being assaulted, and many more, but the most notable option is a nurse-family partnership.36 a nurse-family partnership is a program where specially trained nurses regularly visit the future mothers from the beginning of the pregnancy through the baby's second birthday. in this program, the expectant teens get the support that they need alongside with the tests and assessments necessary to keep the baby healthy. programs like this can help the expectant mothers to keep themselves and the baby healthy throughout the entirety of the undoubtedly stressful pregnancy. another important consideration is whether the teenager will return to school after the baby is born. for those who decide to return to school there are multitudes of opportunities for them. there are many alternative pathways that teenage mothers can take to further their education. the most common option would be the general education development test, or ged. the ged exam allows people who did not earn a high school diploma to receive a diploma and recognition that they have a high school level of education.37 other alternative programs include alternative high schools that are specifically geared towards teenage mothers and their babies. conclusion teen mothers must adjust to, not only the demands and responsibilities of parenting, but navigate the developmental process into adulthood. with dramatic hormonal changes leading to differing structures of the brain and certain stressors such as guilt and bullying, teenage pregnancy can contribute to a range of mental health problems such as ptsd and depression. by educating adolescents on preventative methods and postnatal opportunities, there is a possibility of decreasing the prevalence and mental toll on teenage mothers. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.89 dhr proceedings ǀ http://dhrproceedings.org 49 2023, vol. 2 no. s2 45-50 acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. mann l, bateson d, black ki. teenage pregnancy. aust j gen pract. 2020 jun;49(6):310-316. doi: 10.31128/ajgp-0220-5224. pmid: 32464731. 2. -leftwich hk, alves mv. adolescent pregnancy. pediatr clin north am. 2017 apr;64(2):381-388. doi: 10.1016/j.pcl.2016.11.007. epub 2017 jan 3. pmid: 28292453. 3. psychological health and life experiences of pregnant adolescent mothers in jamaica, published: 30 april 2014 4. teenage pregnancy and mental health beyond the postpartum period: a systematic review published february 8, 2018 5. [adolescent parenting – developmental risks for the mother-child dyad] published november 2013 6. merriam-webster. (2019). definition of mental health. merriam-webster.com. 7. cdc. u.s. teen girls experiencing increased sadness and violence. centers for disease control and prevention. published february 13, 2023. 8. cdc. adolescence (15-17 years old). centers for disease control and prevention. published february 22, 2021. 9. corcoran j. teenage pregnancy and mental health. societies. 2016; 6(3):21.(2) 10. rebecca buffum taylor. teen pregnancy: medical risks and realities. webmd.published may 27, 2008. office of population affairs. trends in teen pregnancy and childbearing | hhs 11. carmona s, martínez-garcía m, paterninadie m, et al. pregnancy and adolescence entail similar neuroanatomical adaptations: a comparative analysis of cerebral morphometric changes. human brain mapping. may 2019. accessed august 2, 2023. 12. blakemore s-j, burnett s, dahl re. the role of puberty in the developing adolescent brain. human brain mapping. june 2010. accessed august 2, 2023. 13. gogtay n, giedd jn, lusk l, et al. dynamic mapping of human cortical development during childhood through early adulthood. proceedings of the national academy of sciences of the united states of america. may 25, 2004. accessed august 2, 2023. 14. casey bj, jones rm, hare ta. the adolescent brain. annals of the new york academy of sciences. march 2008. accessed august 2, 2023. 15. biobehavioral processes the science of adolescent risk-taking ... accessed august 3, 2023. 16. arain m, haque m, johal l, et al. maturation of the adolescent brain. neuropsychiatric disease and treatment. 2013. accessed august 2, 2023. 17. hodgkinson s, beers l, southammakosane c, lewin a. addressing the mental health needs of pregnant and parenting adolescents. pediatrics. january 2014. accessed august 2, 2023. 18. cárdenas ef, kujawa a, humphreys kl. neurobiological changes during the peripartum period: implications for health and behavior. social cognitive and affective neuroscience. november 10, 2020. accessed august 2, 2023. 19. henry jf, sherwin bb. hormones and cognitive functioning during late pregnancy and postpartum: a longitudinal study. behav neurosci. 2012;126(1):73-85. doi:10.1037/a0025540 20. barda g, mizrachi y, borokchovich i, yair l, kertesz dp, dabby r. the effect of pregnancy on maternal cognition. scientific reports. 2021;11(1):12187. doi:https://doi.org/10.1038/s41598-02191504-9 21. ramsey a. cognitive development in children | stages & changes in adolescence. www.cincinnatichildrens.org. published 2020. 22. leppert pc. the effect of pregnancy on adolescent growth and development. women health. 1984;9(2-3):65-79. doi:10.1300/j013v09n02_05 23. morinis j, carson c, quigley ma. effect of teenage motherhood on cognitive outcomes special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.89 dhr proceedings ǀ http://dhrproceedings.org 50 2023, vol. 2 no. s2 45-50 in children: a population-based cohort study. arch dis child. 2013;98(12):959-964. doi:10.1136/archdischild-2012-302525 24. cruz e, cozman fg, souza w, takiuti a. the impact of teenage pregnancy on school dropout in brazil: a bayesian network approach. bmc public health. 2021;21(1):1850. published 2021 oct 13. doi:10.1186/s12889-021-11878-3 25. xavier c, benoit a, brown hk. teenage pregnancy and mental health beyond the postpartum period: a systematic review. j epidemiol community health. 2018;72(6):451-457. doi:10.1136/jech-2017209923 26. allen j, balfour r, bell r, marmot m. social determinants of mental health. int rev psychiatry. 2014;26(4):392-407. doi:10.3109/09540261.2014.928270 27. onoye jm, shafer la, goebert da, morland la, matsu cr, hamagami f. changes in ptsd symptomatology and mental health during pregnancy and postpartum. arch womens ment health. 2013;16(6):453-463. doi:10.1007/s00737-013-0365-8 28. onoye jm, goebert d, morland l, matsu c, wright t. ptsd and postpartum mental health in a sample of caucasian, asian, and pacific islander women. arch womens ment health. 2009;12(6):393-400. doi:10.1007/s00737-009-0087-0 29. bellieni cv, buonocore g. abortion and subsequent mental health: review of the literature. psychiatry clin neurosci. 2013 jul;67(5):301-10. doi: 10.1111/pcn.12067. pmid: 23859662. 30. kukulskienė m, žemaitienė n. postnatal depression and post-traumatic stress risk following miscarriage. int j environ res public health. 2022 may 27;19(11):6515. doi: 10.3390/ijerph19116515. pmid: 35682100; pmcid: pmc9180236. 31. about teen pregnancy | cdc. www.cdc.gov. published november 15, 2021. 32. mangel l. teen pregnancy, discrimination, and the dropout rate. aclu of washington. published october 25, 2010. 33. 1.broster a. fewer than half of american women were taught about birth control, study finds. forbes. accessed august 3, 2023. https://www.forbes.com/sites/alicebroster/20 20/08/20/less-than-half-of-people-weretaught-about-birth-control-saysstudy/?sh=6002feb764ba 34. gates r. the role of education in preventing teenage pregnancy. healthcore clinic. published may 11, 2023. accessed august 3, 2023. 35. oash. strategies and approaches for prevention | hhs office of population affairs. opa.hhs.gov. 36. luca dl, stevens j, rotz d, goesling b, lutz r. evaluating teen options for preventing pregnancy: impacts and mechanisms. journal of health economics. 2021;77:102459. 37. mangel l. teen pregnancy, discrimination, and the dropout rate. aclu of washington. published october 25, 2010. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.83 dhr proceedings ǀ http://dhrproceedings.org 19 2023, vol. 2 no. s2 19-23 commentary how breast cancer treatments affect hispanic psychologically post-treatment samantha n. espinoza1,2, elise hernandez1,3, fernando saucedo jr.1,3, estevan bonilla1,3, natasha perez1,4, julian gonzalez jr.1,4, abigail herrera1,2, savannah n. puente1,2, faith l. perez1,4, iliana rios1,4 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 weslaco high school, tx 3 harlingen high school, tx 4 santa rosa high school, tx received: june 16, 2023 accepted for publication: october 25, 2023 published: november 16, 2023 introduction in the united states, breast cancer accounts for nearly 30% of all new cancer cases each year.1 it is the primary cause of cancer death among hispanic women and the second highest cause of cancer death among all females.2 according to the breast cancer research foundation, hispanic women are more likely to experience an earlier onset of an aggressive illness such as triple-negative breast cancer.3 in the united states, every year, about 264,000 women are diagnosed with breast cancer. among these women, around 39% reported non-specific distress, 34% experienced anxiety, 31% reported symptoms of posttraumatic stress, and 20% experienced depression following their diagnosis.4 awareness of a cancer diagnosis can cause severe emotional distress, creating a psychological imbalance among patients, subsequently affecting their quality of life. following a patient’s diagnosis, there are many factors that contribute to adverse psychological effects related to therapies and treatment such as chemotherapy, hormonal therapy, medical menopause, and hypothyroidism.5 in addition to this, therapies themselves can cause patients to experience common side effects such as fatigue, nausea/vomiting, diarrhea, constipation, pain, arm swelling, shortness of breath, and skin irritation.6 in addition to the conflicting symptoms and effects one may experience during surgery, an entire new set of complications derive from previous treatments, further advancing one's psychological state. surgeries such as lumpectomies and mastectomies can also affect the quality of life of patients as it alters their body, leading to loss of selfconfidence. the physical side effects of breast cancer treatment can include altered body shape, hair loss, early menopause, and infertility.7 the breast is one of the most common symbols of femininity. thus, the surgical removal of one or both breasts can cause harmful psychological effects on a woman. a woman who has lost a breast may feel self-conscious, insecure, submissive to other women, and less attractive, especially in the eyes of their partner.8 moreover, the cost to cover respective treatments, surgeries, medications, and doctor visits can be expensive, especially if a patient does not have medical insurance. even if one does have insurance, certain treatments not covered by insurance and other out-of-pocket costs can result in significant debt, even after treatment has ended. depending on the severity of their cancer and their health status, patients may not be able to work as much or at all.9 the loss of income can cause significant financial and familial strain, further demonstrating the persisting impacts of breast cancer on patients. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.83 dhr proceedings ǀ http://dhrproceedings.org 20 2023, vol. 2 no. s2 19-23 hispanic women compared to other ethnicities hispanic women, compared to other ethnicities, are at higher risk of going undiagnosed for breast cancer for longer periods of time.10 they are 30% less likely to be diagnosed for the fact that most of them are not exposed to breast cancer screenings or are not aware of its symptoms.3 one of the most effective ways of achieving early identification of breast cancer in women is through routine mammogram screenings. amongst underserved communities, screenings and informational advertisements about breast cancer may not be promoted by any of their healthcare facilities or public health groups. providing breast cancer education and adopting risk education measures, in culturally sensitive and dual language situations, could potentially keep incidence and death by cancer low. within ethnic and racial populations in the united states, differences in the incidence rate, survival rate, and features of the tumor are seen. epidemiologic studies that mostly included non-hispanic white women have discovered risks for breast cancer, which limits an understanding of how important these factors are to different ethnic groups.11 despite hispanics being around 15% of the population in the united states, which is still currently expanding, only very few studies have examined the thorough effects of breast cancer risk factors in these populations. less than 3% of individuals involved in clinical trials are black, 12.7% of americans have african or caribbean heritage. in contrast, compared to the prevalence of cancer, asian communities are typically overrepresented in cancer therapeutic trials.11 clinical research does not have enough diverse patient populations. it mainly includes non-hispanic white populations, which restricts our understanding of significant biological and social distinctions that may influence the development of treatments. body image “i look in a mirror and the result is deformity. nothing, but just deformity,” a quote stated by one of many breast cancer survivors.12 society today tends to portray what the perfect female body should look like. body image is the depiction of one’s own body in their own mind. breast cancer survivors suffer with selfconfidence and body image due to the fact that they undergo many different treatments that can physically alter their appearance, such as chemotherapy. chemotherapy is the practical use of powerful chemicals that are inserted through the bloodstream intravenously (iv).13 this treatment destroys both tumor and healthy cells and can result in hair loss. this feminine feature is very significant to women as it plays a part in defining their identity as a woman.8 mastectomies which are the surgical removal of one or both breasts is another treatment that physically alters the appearance of a woman’s body. over 100,000 women receive mastectomies annually.14and therefore a large portion of the us female population is affected. a study conducted by remmers, et.al., surveyed volunteers who participated in a report about the afterthought of themselves being frightened and startled when they first saw the surgical site.15 this can trigger many emotions such as depression, anxiety, and a lack of self-confidence. because of this, having this form of cancer can leave a heavy toll on the mental and physical state of the human body. mental disorders and other psychological factors depression, anxiety, decrease in selfconfidence are some of many psychological effects that breast cancer survivors experience during and after their treatments.17 however, in hispanic households, acknowledgement of mental health issues are either entirely avoided or perceived as non-existent or abnormal.18 therefore, when they are diagnosed with breast cancer, the psychological effects that come from the diagnosis are generally disregarded since they don’t get the proper information on mental health and that way they won’t be seen as unstable.18 we will go into deeper discussion on how these psychological disorders affect the hispanics women with the discussion on the two most impacting disorders: depression and anxiety. depression or major depressive disorder is a mental illness that affects not only your psychological well-being but your physical well-being too.19 it can affect their mental stability which in turn has them not only isolate themselves from others, but also make a simple task seem impossible. for instance, just getting up to shower, brushing their teeth, and keeping up with their hygiene can be hard for someone who is suffering from this condition.20 others who have not gone through this experience themselves may be quick to judge and think “it’s such a simple task, they're just being lazy” when they don’t even know what it actually feels like to battle yourself within your mind. the fuel that is added to one's depression is also having low selfesteem. especially since most breast cancer survivors result in getting a mastectomy as previously mentioned. the scarring that comes from the surgical procedure may worsen their isolation from society. one quote that shows this is from a participant from a study on how body image is perceived in women after special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.83 dhr proceedings ǀ http://dhrproceedings.org 21 2023, vol. 2 no. s2 19-23 their mastectomies. the quote states “i didn’t want to see the operation area at all; i saw it when i was back home. before seeing it, i knew that i was going to feel the emptiness but when i saw it, i felt very different (crying), words are never enough to explain”.16 therefore, insecurity and lack of self-confidence will hold them back from living life and being who they were before the cancer. anxiety is another mental health illness that can affect many women with breast cancer. in a recent study, 32% of breast cancer patients experienced symptoms of anxiety.21 having anxiety impacts these women's lives. anxiety is an emotional disorder which happens because of stress but when it's a disorder it gets worse and doesn't go away.22 for breast cancer survivors it is fearing recurrence, hopelessness, fearing for the worst and uncertainty of the future. anxiety may affect a patient’s ability to complete daily tasks of everyday life. it can creep up all of a sudden with panic and may go away at any given time. it can affect a person's life by getting in the way of family and friends, job performance, and social skills. self-confidence is also greatly affected by breast cancer diagnosis and may stop the patient's ability to be around people. patient’s may get overwhelmed by going out so they usually avoid interacting with others. however, anxiety affects your mental and physical health. some of the physical effects are being restless, nauseous, light headed or dizzy, and stomachaches.23 you can also get panic attacks when someone or something reminds you of those hard times. people who have experienced anxiety before know the symptoms and how it feels, but those patients who have never experienced anxiety aren't prepared for it. disturbance in social life the way of life, beliefs, and values that are passed down from one generation to the next, also known as culture, can impact how people view and manage their health and well-being, as well as their perception of the world in a situation where something seems unmanageable, like being diagnosed with breast cancer. along with mental health issues among breast cancer survivors, specifically hispanic women, there are a variety of social repercussions that affect their quality of life. in a 2011 survey, researchers from georgetown university found reoccurring themes present throughout the lives of hispanic women post treatment such as shame, religion, and more which have impacted their standard of living.24 their social interactions are often limited due to strains on their physical health leading to feelings of isolation, including a sense of burden. additionally, they may be incapable of performing their assigned familial role leading to further sense of isolation.25 furthermore, studies on breast cancer survivors exhibit how hispanic women are especially receptive towards stigmas and responses from family members concerning their illness and how marianismo, a gender role expressing female submissiveness, plays another factor to their social life.26 for instance, some women may feel cultural pressure to remain an all-nurturing figure and even self-sacrificial for the benefit of their husbands. this can also create extensive loneliness as patients refuse to discuss the disease with their spouses. in addition to survivors’ concerns and fears, another notable factor that dictates their quality of life socially is their religion. as for the survey listed above, the majority of hispanic women put their fears and concerns aside, after their diagnosis, in order to find consolation in god.24 however, that isn’t always the case for all patients. others have reported their diagnosis and post-treatment complications were a punishment from god, which led them to question their commitment, because most of these patients depended on religious support to determine the bulk of their well-being.27 for instance, solidarity from religion has been linked to higher quality of life for patients suffering with cancer.27 qualitative studies on this demographic, hispanic women, propose that cultural components demonstrate a distinct vulnerability throughout their experience of breast cancer from diagnosis, treatment, and to remission. conclusion current evidence supports the fact that hispanic women with breast cancer have a difficult time processing their diagnosis. once being diagnosed, there are drastic changes to their bodies, body image, mental health, and social life. once therapy begins, patients' perceptions of their bodies start to change as a result of losing things such as hair, breasts, and self-confidence. between 40% and 100% patients experience hair thinning, 59.3% reduced in hair volume and 62.5% of patients' hair didn't come back after treatment.28 mental health issues can have an impact on an individual both during and after treatment, including insomnia, severe anxiety and depression. the rate of breast cancer patients getting depression ranges from 1.5-50% depending on the diagnosis.29 patients' social lives affect how they interact with their family and friends throughout therapy, and some even start to doubt their religious beliefs and ask god why they were diagnosed. pooled data from studies showed that 45% reported high levels of social difficulty.30 therefore, having more awareness and understanding of said issues can tremendously aid the patient's recovery. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.83 dhr proceedings ǀ http://dhrproceedings.org 22 2023, vol. 2 no. s2 19-23 resources that hispanic women can use to cope with their diagnosis are susan g. komen, herconnection, 24/7 cancer helpline, mary ann liebrt, and patient-centered outcomes research institute. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. breastcancer.org. breast cancer facts and statistics. www.breastcancer.org. published march 10, 2022. https://www.breastcancer.org/facts-statistics 2. cdc. cdc basic information about breast cancer. cdc. published 2019. https://www.cdc.gov/cancer/breast/basic_inf o/index.htm 3. object object. what hispanic women and latinas need to know about breast cancer. breast cancer research foundation. published october 10, 2021. https://www.bcrf.org/blog/hispanic-latinabreast-cancer-facts-statistics/ 4. fortin j, leblanc m, elgbeili g, cordova mj, marin mf, brunet a. the mental health impacts of receiving a breast cancer diagnosis: a meta-analysis. british journal of cancer. 2021;125(11):1-11. doi:https://doi.org/10.1038/s41416-02101542-3 5. how breast cancer can affect mental health. www.breastcancer.org. https://www.breastcancer.org/managinglife/taking-care-of-mental-health/howbreast-cancer-affects-mental-health 6. how many women have severe side effects? breastcancer.org. published february 9, 2017. https://www.breastcancer.org/researchnews/tx-causes-severe-side-effects-for-many 7. australia h. living with breast cancer. www.healthdirect.gov.au. published december 20, 2021. https://www.healthdirect.gov.au/living-withbreastcancer#:~:text=the%20physical%20change s%20that%20can 8. spencer kw. significance of the breast to the individual and society. plastic surgical nursing: official journal of the american society of plastic and reconstructive surgical nurses. 1996;16(3):131-132. https://pubmed.ncbi.nlm.nih.gov/9060751/ 9. legal & financial impacts of cancer. md anderson cancer center. accessed june 15, 2023. https://www.mdanderson.org/patientsfamily/life-after-cancer/legal-financialimpacts.html#:~:text=cancer%20treatment %20costs%20not%20covered 10. davis j. breast cancer: how it affects latina and hispanic women. webmd. https://www.webmd.com/breastcancer/breast-cancer-latina-hispanic-women 11. hines lm, risendal b, slattery ml, et al. comparative analysis of breast cancer risk factors among hispanic and non-hispanic white women. cancer. 2010;116(13):32153223. doi:https://doi.org/10.1002/cncr.25154 12. kocan s, gursoy a. body image of women with breast cancer after mastectomy: a qualitative research. journal of breast health. 2016;12(4):145-150. doi:https://doi.org/10.5152/tjbh.2016.2913 13. mayo clinic. chemotherapy mayo clinic. mayoclinic.org. published march 5, 2020. https://www.mayoclinic.org/testsprocedures/chemotherapy/about/pac20385033 14. mastectomy and double mastectomy brigham and women’s hospital. www.brighamandwomens.org. https://www.brighamandwomens.org/surger y/surgicaloncology/resources/mastectomy#:~:text=mo re%20than%20100%2c000%20u.s.%20wo men 15. kocan s, gursoy a. body image of women with breast cancer after mastectomy: a qualitative research. journal of breast health. 2016;12(4):145-150. doi:https://doi.org/10.5152/tjbh.2016.2913 16. izci f, ilgun as, findikli e, ozmen v. psychiatric symptoms and psychosocial problems in patients with breast cancer. journal of breast health. https://www.breastcancer.org/facts-statistics https://www.cdc.gov/cancer/breast/basic_info/index.htm https://www.cdc.gov/cancer/breast/basic_info/index.htm https://www.bcrf.org/blog/hispanic-latina-breast-cancer-facts-statistics/ https://www.bcrf.org/blog/hispanic-latina-breast-cancer-facts-statistics/ https://www.breastcancer.org/managing-life/taking-care-of-mental-health/how-breast-cancer-affects-mental-health https://www.breastcancer.org/managing-life/taking-care-of-mental-health/how-breast-cancer-affects-mental-health https://www.breastcancer.org/managing-life/taking-care-of-mental-health/how-breast-cancer-affects-mental-health https://www.breastcancer.org/research-news/tx-causes-severe-side-effects-for-many https://www.breastcancer.org/research-news/tx-causes-severe-side-effects-for-many https://www.healthdirect.gov.au/living-with-breast-cancer#:~:text=the%20physical%20changes%20that%20can https://www.healthdirect.gov.au/living-with-breast-cancer#:~:text=the%20physical%20changes%20that%20can https://www.healthdirect.gov.au/living-with-breast-cancer#:~:text=the%20physical%20changes%20that%20can https://www.healthdirect.gov.au/living-with-breast-cancer#:~:text=the%20physical%20changes%20that%20can https://pubmed.ncbi.nlm.nih.gov/9060751/ https://www.mdanderson.org/patients-family/life-after-cancer/legal-financial-impacts.html#:~:text=cancer%20treatment%20costs%20not%20covered https://www.mdanderson.org/patients-family/life-after-cancer/legal-financial-impacts.html#:~:text=cancer%20treatment%20costs%20not%20covered https://www.mdanderson.org/patients-family/life-after-cancer/legal-financial-impacts.html#:~:text=cancer%20treatment%20costs%20not%20covered https://www.mdanderson.org/patients-family/life-after-cancer/legal-financial-impacts.html#:~:text=cancer%20treatment%20costs%20not%20covered https://www.webmd.com/breast-cancer/breast-cancer-latina-hispanic-women https://www.webmd.com/breast-cancer/breast-cancer-latina-hispanic-women https://www.mayoclinic.org/tests-procedures/chemotherapy/about/pac-20385033 https://www.mayoclinic.org/tests-procedures/chemotherapy/about/pac-20385033 https://www.mayoclinic.org/tests-procedures/chemotherapy/about/pac-20385033 https://www.brighamandwomens.org/surgery/surgical-oncology/resources/mastectomy#:~:text=more%20than%20100%2c000%20u.s.%20women https://www.brighamandwomens.org/surgery/surgical-oncology/resources/mastectomy#:~:text=more%20than%20100%2c000%20u.s.%20women https://www.brighamandwomens.org/surgery/surgical-oncology/resources/mastectomy#:~:text=more%20than%20100%2c000%20u.s.%20women https://www.brighamandwomens.org/surgery/surgical-oncology/resources/mastectomy#:~:text=more%20than%20100%2c000%20u.s.%20women https://www.brighamandwomens.org/surgery/surgical-oncology/resources/mastectomy#:~:text=more%20than%20100%2c000%20u.s.%20women special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.83 dhr proceedings ǀ http://dhrproceedings.org 23 2023, vol. 2 no. s2 19-23 2016;12(3):94-101. doi:https://doi.org/10.5152/tjbh.2016.3041 17. national alliance on mental illness. hispanic/latinx | nami: national alliance on mental illness. nami.org. published 2018. https://www.nami.org/yourjourney/identity-and-culturaldimensions/hispanic-latinx 18. torres f. what is depression? american psychiatric association. published 2020. https://www.psychiatry.org/patientsfamilies/depression/what-is-depression 19. debattista c. executive dysfunction in major depressive disorder. expert review of neurotherapeutics. 2005;5(1):79-83. doi:https://doi.org/10.1586/14737175.5.1.79 20. lee ms, tyson dm, gonzalez bd, et al. anxiety and depression in spanish-speaking latina cancer patients prior to starting chemotherapy. psycho-oncology. 2017;27(1):333-338. doi:https://doi.org/10.1002/pon.4462 21. national institute of mental health. anxiety disorders. national institute of mental health. published april 2022. https://www.nimh.nih.gov/health/topics/anxi ety-disorders 22. nimh» anxiety disorders. www.nimh.nih.gov. https://www.nimh.nih.gov/health/topics/anxi ety-disorders#part_2223 23. lopez-class m, perret-gentil m, kreling b, caicedo l, mandelblatt j, graves kd. quality of life among immigrant latina breast cancer survivors: realities of culture and enhancing cancer care. j cancer educ. 2011;26(4):724-733. doi:10.1007/s13187011-0249-4 24. yanez b, thompson eh, stanton al. quality of life among latina breast cancer patients: a systematic review of the literature. j cancer surviv. 2011;5(2):191-207. doi:10.1007/s11764-011-0171-0 25. elimimian e, elson l, bilani n, et al. longterm effect of a nonrandomized psychosocial mindfulness-based intervention in hispanic/latina breast cancer survivors. integr cancer ther. 2020;19:1534735419890682. doi:10.1177/1534735419890682 26. flores nj, mathew mj, fortson ls, abernethy ad, ashing kt. the influence of culture, social, and religious support on well-being in breast cancer survivorship. cureus. 2021;13(3):e14158. published 2021 mar 28. doi:10.7759/cureus.14158 27. kang d, kim i, choi e, et al. permanent chemotherapy‐induced alopecia in patients with breast cancer: a 3‐year prospective cohort study. the oncologist. 2019;24(3):414-420. doi:https://doi.org/10.1634/theoncologist.20 18-0184 28. her2-positive breast cancer support. herconnection. accessed june 15, 2023. https://www.herconnection.com 29. van roij j, brom l, youssef-el soud m, van de poll-franse l, raijmakers njh. social consequences of advanced cancer in patients and their informal caregivers: a qualitative study. supportive care in cancer. 2018;27(4):1187-1195. doi:https://doi.org/10.1007/s00520-0184437-1 https://www.nami.org/your-journey/identity-and-cultural-dimensions/hispanic-latinx https://www.nami.org/your-journey/identity-and-cultural-dimensions/hispanic-latinx https://www.nami.org/your-journey/identity-and-cultural-dimensions/hispanic-latinx https://www.psychiatry.org/patients-families/depression/what-is-depression https://www.psychiatry.org/patients-families/depression/what-is-depression https://www.nimh.nih.gov/health/topics/anxiety-disorders https://www.nimh.nih.gov/health/topics/anxiety-disorders https://www.nimh.nih.gov/health/topics/anxiety-disorders#part_2223 https://www.nimh.nih.gov/health/topics/anxiety-disorders#part_2223 https://www.herconnection.com/ special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 106 2022, vol. 2 no. s2 106-115 commentary breast cancer in men michael garza1,2, adamari morin1,2, abigail godinez1,2, ian luna1,3, marianna silva1,2, danica escobedo1,3, melissa gonzalez1,2, america perales1,2, nathalie palacios1,2, camila urquizo1,2 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2mission high school, mission, tx 3pharr san juan alamo high school, pharr, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 08/04/2022 accepted for publication 08/15/2022 published 08/16/2022 introduction breast cancer is the rapid growth and division of cells in the breast’s anatomy [1]. it’s well-known and well-studied because of its common occurrence and high incidence in women [2]. estimates made by the national cancer institute show that breast cancer is the most frequently diagnosed cancer in the united states in 2022[3]. however, it's unknown to many that men can also develop breast cancer [4]. while cases are rare, its presentation and prognosis in men, the development of the disease, the genetic mutations that show higher risk of breast cancer in one sex over the other, and slight but notable differences in the pathophysiology of male breast cancer compared to female breast cancer are topics worthy of discussion and further study [5]. male breast cancer is a relatively misunderstood and understudied disease due to its rarity in the sex [6]. less than 1% of all breast cancers are found in men, and less than 1% of all cancers found in men are breast cancers [7]. still, the disease is a serious topic worthy of discussion as rates of male breast cancer have steadily risen each year all across the globe [8]. this may be in part due to risk factors such as obesity and hormonal imbalances being more prevalent in the present day [9]. additionally, genetic mutations such as brca1 and brca2 can predispose some men to develop male breast cancer, and are more likely to develop the disease if they have a blood relative who has developed breast cancer [10]. most men do not properly screen themselves for the disease and most are completely unaware of what symptoms of the condition may present as. this leads to diagnosis at later stages of the disease [11, 12]. stigmatization also plays a role in delayed diagnosis and treatment leading to a significantly higher mortality rate when diagnosed with breast cancer than women [13-16]. unfortunately, because of the rarity of the disease and its lack of understanding even in the medical community, primary care providers and other physicians who are unaware of how to recognize, manage, or treat male breast cancer may delay treatment or refer patients to another doctor who is inexperienced in diagnosing the disease [17]. more research on the disease in men is needed and awareness should be raised in the community and medical field. prognosis since male breast cancer is found in less than 1% of any type of cancers in men and less than 1% in breast cancer in the unites of states, there is little information about its etiology. a research study that investigated the differences between men and women in regards to mortality and survival rates in breast cancer found that breast cancer in men is diagnosed in a higher stage than in women, since it is detected later garza, et al breast cancer in men https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 107 2022, vol. 2 no. s2 106-115 on [18]. unlike women, screening allows for breast cancer to be detected and treated earlier than it is for men. there are 2 main subtypes, one being the complex subtype which seems to be similar to the female luminal breast cancer. then there’s the male simplex subtype that does not exist in female breast cancer. breast tissue consists of milk-producing glands (lobules), ducts that carry milk to the nipples, and fat [10]. during puberty, women begin developing more breast tissue, and men do not. but because men are born with a small amount of breast tissue, they can develop breast cancer. if men have been diagnosed with breast cancer, they might need more tests to see if the cancer might have spread [19]. some possible symptoms of breast cancer in males include lumps or masses in the breast area. however, it's important not to rely on these alone. you should also see your doctor if you notice any unusual changes in size, shape and feel of one or both of your breasts. it's important to remember that the symptoms of breast cancer in males aren't the same as those of women. knowing the common symptoms can help you get early treatment and make sure that you're getting regular checkups from your doctor. as we know, bc in males is quite rare. however, there are several explanations that may help men understand how breast cancer can happen in men. we have age, overall health, estrogen levels, family history, genes, radiation therapy, and testicular issues [20]. first of all, those men who are 60 years or older are more likely to develop breast cancer. it is not common for men to experience gynecomastia. however, a condition known as gynecomastia is a condition that occurs in a few men, that is an enlargement of the male breast gland or fat tissue in the chest area. if you have a first degree relative (mother, sister, or daughter) with bc, you have an increased risk of developing the disease yourself. estrogen is a hormone produced by the ovaries. certain drugs, cirrhosis and klinefelter syndrome increase estrogen levels, increasing the risks of several health problems, including bc. scientists have identified several genes that affect your risk of developing breast cancer. these include changes in the brca1 and brca2 genes. those who have had radiation therapy in the chest or torso, have a higher risk of developing bc. last but not least, the removal of the testicles increases a man’s risk of breast cancer because he does not produce testosterone. testicle injuries also increase the risk [21]. prevalence according to the american cancer society, 2,700 men are diagnosed with breast cancer, meaning one in every 833 men will be victims and nearly 530 die from the disease [22]. this is actually less than one percent of male population and much lower than the rate of breast cancer in women, making it very easy to ignore. however, male breast cancer has been proven to be more prevalent depending on race. it has been shown to be higher in non-hispanic black races and whites [23]. they are 1.2-1.5 times more likely to get diagnosed with breast cancer. another main factor is age. even though it is a disease that is present in all ages, it is much more common in individuals who are 60+ years old. mortality rates also increase with age, but most cases are treated while in stage ii [24]. in addition, location also seems to play a significant role. it has been shown to be more common in metro areas, according to the national cancer database [25]. in fact, numbers in metro areas are larger than rural and urban populations combined. this especially applies to east and central regions rather than western ones. in the past years, this disease has been shown to increase in both male and females. over the last 10 years, the rate has gone from 7% to 10.3 % [26]. the good news is that, although breast cancer in men is gaining more prevalence, death rates have remained low and are progressively decreasing. risk factors proneness to breast cancer amongst men starts increasing at the age of 50. risk factors include genetic mutation, family history of breast cancer, exposure to estrogen, alcohol, liver disease, klinefelter’s syndrome, testicle disease or surgery [27]. there is a current lack of awareness regarding the role of obesity in male breast cancer. men with a 35% high bmi have a greater risk than men with a low bmi [28]. table 1 includes risk factors for male breast cancer. genetics genetics dictate all physical characteristics within all living organisms including, predisposition to diseases, allergies and mutations. male breast cancer (mbc) is no different. modern technology such as polymerase chain reaction (pcr), gene probes, oligonucleotide arrays, microchips and nextgeneration sequencing technologies permit us to analyze genes and their roles within the body such as, garza, et al breast cancer in men https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 108 2022, vol. 2 no. s2 106-115 susceptibility to certain conditions [30]. if the patient has a positive family history from mbc, then the genetic likelihood for them contracting is increased compared to another man with a negative family history with 10% of all mbc cases caused by inherited gremlin mutations. genes are classified as highpenetrance, moderate-penetrance and low-penetrance. genes known to increase likelihood for developing mbc include brca1 & brca2 as high penetrance, the level of penetrance of a gene is determined by the rate of mutation and magnitude of impact. known high penetrance genes involved in mbc include brca1 and brca2 which when mutated point at a high risk to developing mbc whilst variants of the genes can have a <5% moderate risk factor and chek 2 & palb2. with recent findings pointing at a lowpenetrance group of mbc susceptible alleles but their low penetrance leaves ambiguity in their direct correlation to breast cancer [31]. table 2 outlines the classes of male breast cancer genetic susceptibility and comparison of their different features and figure 1 shows the regularity of gene mutations in mbc tumors. treatments there are different ways breast cancer in men can be treated, it can be as simple as taking medication to as complicated as needing radiation. treatments in male and female breast cancer are similar but most male patients will undergo radiation therapy and mastectomy, while female patients most commonly partake in chemotherapy and lumpectomy [33]. male and female treatments involve: surgery, chemotherapy, radiation therapy, hormone therapy, and targeted therapy [34]. surgery, in surgery treatment there are two main types: lumpectomy and mastectomy [35]. a lumpectomy surgery removes the tumor and small parts of normal tissue; while a mastectomy surgery removes the whole breast which may include part of the skin, nipple, areola, and lymph nodes. chemotherapy, chemotherapy is a treatment that can be taken by pill or injection, the drug helps prevent growth of more cancer cells by either stopping the cells from dividing or killing them. hormone therapy, hormone therapy is a treatment that is used only for hormone sensitive cancers, it stops hormones or blocks hormone receptors from attaching to cancer cells to prevent or decrease the production of hormones [36]. radiation therapy, radiation therapy is a treatment that involves high energy x-rays and radiation to kill or keep cancer cells from growing. there are two types of radiation therapy: external and internal radiation. external radiation uses a machine that delivers radiation outside the body towards the cancerous area and internal radiation is a device that is temporarily placed on the cancerous area after surgery [37]. targeted therapy, targeted therapy causes the least amount of harm to normal cells then other breast cancer treatments, this treatment uses drugs to identify specific cancer cells and attack protein that makes cancer cells grow in an abnormal way [38]. clinical trials, clinical trials are a type of research study that helps improve ongoing treatments or collect information to help with new treatments. for many patients, clinical trials are the best treatment option. some trials use patients that have yet to be treated and others whose cancer has not improved. clinical trials are starting to take place all over the country helping to determine how cancer will get treated in the future. however, risk of having breast cancer and going through treatment can be reduced by keeping a healthy weight and exercising regularly. awareness since breast cancer in males is not as prevalent within the population, there is a lack of awareness that contributes to many late diagnoses [39]. a majority of 81% of men that have been diagnosed were not aware of the presence of their illness, while only 19% of men were aware that they had cancer [40]. these statistics occurred as a result of the lack of knowledge provided about the sickness and the symptoms that can occur. depending on the growth of the cancerous cells, it can be easier to detect breast cancer in men if the growth is around the mammary papilla because the abnormal lumps would be more visible compared to those found in women [41]. however, since men's breast tissue is smaller in mass, the possibility of the cancerous cells multiplying behind the teat can increase the potential of being diagnosed late. while women have yearly checkups and a screening process with their physicians to make sure that these abnormalities are not occurring within the breast, males have no sort of confirmation to provide reassurance that they themselves are not developing abnormalities [42]. this information is extremely important to know to help the prevention of growth, but yet not many males are provided this information, and as a result, many lives are lost. learning about breast cancer in men can reduce the risk of late diagnosis and help provide treatment in the early stages of development. by raising awareness and improving the educational process in which we inform males about the possibility of breast cancer, we can eliminate the social stigma of breast cancer in men, and prevent the progression of cancer development, helping to save many lives. garza, et al breast cancer in men https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 109 2022, vol. 2 no. s2 106-115 the stigma: a woman’s disease in men when the general population fears a diagnosis, namely cancer, it tends to become a stigma in society. stigmatization can lead to becoming isolated and excluded socially via loss of employment which can lead to loss of household and social status. a newly diagnosed male having what is traditionally misconceived as “a woman’s disease” can end up with a negatively impacted sense of self identity. emasculation is also a likely result of a male breast cancer (mbc) diagnosis [43]. another factor that promulgates the stigma is sexism. breast cancer screening is established in preventive medicine care for female patients, while prostate cancer screening is the preventive medicine focus for male patients [44]. in a qualitative study on mbc for participants ages 5383, the participants expressed uncertainty in using tamoxifen for their hormone treatment. they felt there should be a need to study the effectiveness of the hormone based drug in males. furthermore, there are many advertisements for solutions to chemotherapy induced problems with respect to body image such as the use of special bras and breast implants, and hair replacement for females, but not for males [45, 46]. hair loss and alopecia due to chemotherapy are issues that cause distress in both males and females. yet, very few academic or medical journal articles can be found on the topic of male alopecia due to mbc treatment. study results reveal that males are not able to hide hair loss, and females have more tools available to decrease the appearance of hair loss. also, males tend to make jokes to hide insecurities caused by hair loss [47]. healthcare providers need to better understand the underlying of how patients deal with mbc as compared to females in order to better address their social and psychological needs. by anticipating mbc patients’ emotional, psychological and physical needs, the effects of stigmatization may be minimized. survival rate if you haven't been diagnosed with male breast cancer and you have a brca1 or brca2 mutation, your doctors may recommend that you receive periodic screenings for breast cancer and other cancers [48]. the 5-year survival rate for men with breast cancer is 84%. the survival rate depends on different factors, including the stage of disease when it is first diagnosed. study shows that about 47% of cases are diagnosed at this localized stage. it is important to remember that statistics on the survival rate for men with breast cancer are at an estimate. the estimate comes from annual data based on the number of men with this cancer in the united states. also, experts measure the survival statistics every 5 years. this means the estimate may not reflect the results of advancements in how men with breast cancer are diagnosed or treated from the last 5 years. even if the cancer is found at the most advanced stage, new treatments help many people with breast cancer maintain a good quality of life for some time. also it varies on how you respond to the treatment, and depends on how healthy you were before having breast cancer. survival rates can describe any length of given time. however, researchers usually give cancer statistics as a 5-year relative survival rate. there is a 5-year survival rate for men, the 5-year survival rate for men is 84%. there are different types of cancer so it depends what type of cancer you have to know the survival rate. the most common breast cancer found in men is the same kind found in women. survival statistics also help doctors evaluate treatment options. depending on where the cancer spreads, for example if it spreads to a distant part of the body the 5-year survival rate would be 22%. these epidemiologic factors, in addition to studies suggesting that men with breast cancer have elevated estriol production, indicate a relationship between male breast cancer and hormones in addition to the well-established relationship with genetics [49]. it depends on the type of cancer men have and some can have a lower chance of survival rate. the stage of cancer, because sometimes it is worse, for example it could be stage 5 or 1. how you respond to the treatment is also very important. our body’s respond differently to the treatment. your age and how healthy you were before cancer helps a lot and most likely shows how you are going to react to the treatment. treatment and management of male breast cancer typically follow the same rationale of breast cancer in females, which consists of resection followed by adjuvant endocrine therapy, chemotherapy (ct), or radiotherapy [27]. many people do not realize that men have breast tissue and that they can develop breast cancer. the cells in our body can become cancer and can spread to other areas. if you haven't been diagnosed with male breast cancer and you have a brca1 or brca2 mutation, your doctors may recommend that you receive periodic screenings for breast cancer and other cancers. conclusion although breast cancer is one of the least common types of cancer amongst males, risk is still present. with approximately 530 deaths a year and a mortality rate of 0.29%, the uncommonness of the disease does not invalidate its risk of mortality [13,22]. furthermore, current statistics regarding male breast cancer are not believed to accurately encompass reality due to the lack of awareness and societal garza, et al breast cancer in men https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 110 2022, vol. 2 no. s2 106-115 discredit (neglection) within the male population. this causes a vast amount of undiagnosed patients to go unseen or be diagnosed at a late stage contributing to less than 1% of breast cancers diagnosed in men [50]. the low prevalence complicates any further studies on the psychosocial effects of the disease in men, pathophysiological differences in men and women, and the causes behind higher mortality rates. although little research has been conducted regarding the effects of treatment on males with mbc, a recent survey found worse mental and physical health in breast cancer survivors [51]. poorer mental, physical, and emotional health was correlated with obesity, diabetes, and activity limitations in patients with mbc [52]. with mbc being primarily hormone receptor positive, including the androgen receptor (ar) and prevalence of brca2 germline mutation, female breast cancer and mbc are different molecularly (different gene mutations and subtypes) and in histology [10]. due to inadequate research in men, diagnosis and treatments are shy of current scientific advancements available to women [5]. mbc survival rates are overall 4.6 % lower than that of female breast cancer patients [26]. despite biological differences, current treatments for males are mostly based on studies done in women [53]. however, discovery and application of different treatments such as poly-adp-ribosome polymerase (parp) inhibitors, sex-steroid biosynthesis pathway, and ar activation (targeted agents) are promising for the treatment of mbc [10]. as the rate of mbc incidence increases yearly, global cooperation and further research is imperative for the further advancement of treatment and awareness [26]. there is evidence that spreading awareness amongst patients and medical professionals leads to an increase in early-stage detection leading to overall and disease-free survival [10, 26]. there is an opportunity to develop education and awareness campaigns and research done on the disease as a whole, making it easier to inform the public and healthcare providers on how to properly diagnose, manage, and treat breast cancer in men. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. what is breast cancer? american cancer society. (n.d.). retrieved july 29, 2022, from https://www.cancer.org/cancer/breastcancer/about/what-is-breast-cancer.html 2. liu, n., johnson, k. j., & ma, c. x. (2018). male breast cancer: an updated surveillance, epidemiology, and end results data analysis. clinical breast cancer, 18(5), e997–e1002. https://doi.org/10.1016/j.clbc.2018.06.013 3. national cancer institute. (2015, april 21). common cancer types national cancer institute.www.cancer.gov.https://www.canc er.gov/types/common-cancers#: ~:text=the%20most%20common%20type% 20of 4. fentiman i. s. (2018). unmet needs of men with breast cancer. european journal of surgical oncology: the journal of the european society of surgical oncology and the british association of surgical oncology, 44(8), 1123–1126. https://doi.org/10.1016/j.ejso.2018.05.004 5. ruddy, k. j., & winer, e. p. (2013). male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship. annals of oncology: official journal of the european society for medical oncology, 24(6), 1434–1443. https://doi.org/10.1093/annonc/mdt025 6. ding, y. c., steele, l., kuan, c. j., greilac, s., & neuhausen, s. l. (2011). mutations in brca2 and palb2 in male breast cancer cases from the united states. breast cancer research and treatment, 126(3), 771–778. https://doi.org/10.1007/s10549-010-1195-2 7. elbachiri, m., fatima, s., bouchbika, z., benchekroun, n., jouhadi, h., tawfiq, n., sahraoui, s., & benider, a. (2017). cancer du sein chez l’homme: à propos de 40 cas et revue de la littérature [breast cancer in men: about 40 cases and literature review]. the pan african medical journal, 28, 287. https://doi.org/10.11604/pamj.2017.28.287.1 3527 garza, et al breast cancer in men https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 111 2022, vol. 2 no. s2 106-115 8. muir, d., kanthan, r., & kanthan, s. c. (2003). male versus female breast cancers. a population-based comparative immunohistochemical analysis. archives of pathology & laboratory medicine, 127(1), 36–41. https://doi.org/10.5858/2003-127-36mvfb 9. nahleh z. (2011). breast cancer, obesity and hormonal imbalance: a worrisome trend. expert review of anticancer therapy, 11(6), 817–819. https://doi.org/10.1586/era.11.67 10. gucalp, a., traina, t. a., eisner, j. r., parker, j. s., selitsky, s. r., park, b. h., elias, a. d., baskin-bey, e. s., & cardoso, f. (2019). male breast cancer: a disease distinct from female breast cancer. breast cancer research and treatment, 173(1), 37– 48. https://doi.org/10.1007/s10549-0184921-9 11. the difference: male and female breast cancer. cancer treatment centers of america. (2021, december 8). retrieved july 30, 2022, from https://www.cancercenter.com/community/b log/2019/07/whats-the-difference-femalemale-breastcancer#:~:text=%e2%80%9cin%20general %2c%20the%20incidence%20of,medical% 20oncologist%20at%20our%20philadelphia 12. gao, y., heller, s. l., & moy, l. (2018). male breast cancer in the age of genetic testing: an opportunity for early detection, tailored therapy, and surveillance. radiographics: a review publication of the radiological society of north america, inc, 38(5), 1289–1311. https://doi.org/10.1148/rg.2018180013 13. centers for disease control and prevention. (2020, october 1). male breast cancer incidence and mortality, united states-2013– 2017. centers for disease control and prevention. retrieved july 30, 2022, from https://www.cdc.gov/cancer/uscs/about/databriefs/no19-male-breast-cancer-incidencemortality-unitedstates-2013-2017.htm 14. lautrup, m. d., thorup, s. s., jensen, v., bokmand, s., haugaard, k., hoejris, i., jylling, a. b., joernsgaard, h., lelkaitis, g., oldenburg, m. h., qvamme, g. m., soee, k., & christiansen, p. (2018). male breast cancer: a nation-wide population-based comparison with female breast cancer. acta oncologica (stockholm, sweden), 57(5), 613–621. https://doi.org/10.1080/0284186x.2017.141 8088 15. levin-dagan, n., & baum, n. (2021). passing as normal: negotiating boundaries and coping with male breast cancer. social science & medicine (1982), 284, 114239. https://doi.org/10.1016/j.socscimed.2021.11 4239 16. halbach, s. m., midding, e., ernstmann, n., würstlein, r., weber, r., christmann, s., & kowalski, c. (2020). male breast cancer patients' perspectives on their health care situation: a mixed-methods study. breast care (basel, switzerland), 15(1), 22–29. https://doi.org/10.1159/000501956 17. bootsma, t. i., duijveman, p., pijpe, a., scheelings, p. c., witkamp, a. j., & bleiker, e. (2020). unmet information needs of men with breast cancer and health professionals. psycho-oncology, 29(5), 851–860. https://doi.org/10.1002/pon.5356 18. anderson, w. f., jatoi, i., tse, j., & rosenberg, p. s. (2010). male breast cancer: a population-based comparison with female breast cancer. journal of clinical oncology: official journal of the american society of clinical oncology, 28(2), 232–239. https://doi.org/10.1200/jco.2009.23.8162 19. mayo foundation for medical education and research. (2020, february 28). male breast cancer. mayo clinic. retrieved august 3, 2022, from https://www.mayoclinic.org/diseasesconditions/male-breast-cancer/symptomscauses/syc-20374740 20. "signs and symptoms of breast cancer in men." 27 apr. 2018, https://www.cancer.org/cancer/breastcancer-in-men/detection-diagnosisstaging/signs-symptoms.html. accessed 3 aug. 2022. 21. "male breast cancer: what is it, symptoms, treatment & outlook." 15 jun. 2021, https://my.clevelandclinic.org/health/disease s/9011-male-breast-cancer. accessed 3 aug. 2022. 22. (“about breast cancer in men what is breast cancer in men? key statistics for breast cancer in men”) american cancer society, 12 january 2022, https://www.cancer.org/cancer/breastcancer-in-men/about/key-statistics.html. accessed 27 july 2022. 23. (“male breast cancer incidence and mortality, united states—2013–2017 male breast cancer incidence and mortality, united states—2013–2017”) garza, et al breast cancer in men https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 112 2022, vol. 2 no. s2 106-115 24. “stages of male breast cancer.” memorial sloan kettering cancer center, https://www.mskcc.org/cancercare/types/breast-male/diagnosis/stages. 25. sachdev, poonam. “breast cancer in men: symptoms, causes, treatments.” webmd, 21 april 2022, https://www.webmd.com/breastcancer/breast-cancer-men. accessed 3 august 2022. 26. konduri s, singh m, bobustuc g, rovin r, kassam a. epidemiology of male breast cancer. breast. 2020 dec; 54:8-14. doi: 10.1016/j.breast.2020.08.010. epub 2020 aug 22. pmid: 32866903; pmcid: pmc7476060. 27. centers of disease control and prevention. (n.d.). breast cancer in men. cdc. retrieved august 2, 2022, from https://www.cdc.gov/cancer/breast/men/ 28. nci. “nih study confirms risk factors for male breast cancer.” national cancer institute, 19 february 2014, https://www.cancer.gov/news-events/pressreleases/2014/breastcancermalepoolingstudy . accessed 2 august 2022. 29. american cancer society. “risk factors for breast cancer in men what causes breast cancer in men? can breast cancer in men be prevented?” american cancer society, 27 april 2018, https://www.cancer.org/cancer/breastcancer-in-men/causes-risks-prevention/riskfactors.html. accessed 2 august 2022. 30. finegold, d. (2021, july). clinical uses of genetics [review of clinical uses of genetics]. msd manual professional version; merck & co., inc. avid n. finegold, genetic diagnostic technologies, 2021, https://www.msdmanuals.com/professional/s pecial-subjects/general-principles-ofmedical-genetics/genetic-diagnostictechnologies 31. p. rizzolo, v. silvestri, s. tommasi, r. pinto, k. danza, m. falchetti, m. gulino, p. frati, l. ottini,male breast cancer: genetics, epigenetics, and ethical aspects, annals of oncology, volume 24, supplement 8, 2013, pages viii75-viii82,issn09237534,https://doi.org/10.1093/annonc/mdt316 .(https://www.sciencedirect.com/science/arti cle/pii/s0923753419315996) 32. campos fab, rouleau e, torrezan gt, carraro dm, casali da rocha jc, mantovani hk, da silva lr, osório cabt, moraes sanches s, caputo sm, santana dos santos e. genetic landscape of male breast cancer. cancers (basel). 2021 jul 15;13(14):3535. doi: 10.3390/cancers13143535. pmid: 34298749; pmcid: pmc8305894. 33. scott-conner ce, jochimsen pr, menck hr, winchester dj. an analysis of male and female breast cancer treatment and survival among demographically identical pairs of patients. surgery. 1999 oct;126(4):775-80; discussion 780-1. pmid: 10520928. 34. ctca. “the difference: male and female breast cancer.” cancer treatment centers of america, ctca,17,july2019,www.cancercenter.com/ community/blog/2019/07/whats-thedifference-female-male-breast-cancer. accessed 3 aug. 2022. 35. “male breast cancer treatment.” national cancer institute, cancer.gov, 2019, www.cancer.gov/types/breast/patient/malebreast-treatment-pdq. 36. “hormone therapy for breast cancer mayo clinic.” mayoclinic.org, 2019, www.mayoclinic.org/testsprocedures/hormone-therapy-for-breastcancer/about/pac-20384943. 37. mayo clinic. “radiation therapy for breast cancer mayo clinic.” mayoclinic.org, 2018, www.mayoclinic.org/testsprocedures/radiation-therapy-for-breastcancer/about/pac-20384940. 38. “targeted therapy.” www.breastcancer.org, www.breastcancer.org/treatment/targetedtherapy. 39. al-haddad m. (2010). breast cancer in men: the importance of teaching and raising awareness. clinical journal of oncology nursing, 14(1), 31–32. https://doi.org/10.1188/10.cjon.31-32 40. goyal, a., gupta, j., choudhary, a., harit, k., ragesvari, k. s., & gupta, i. (2020). awareness about breast cancer in males in urban area of delhi. journal of family medicine and primary care, 9(4), 1999–2001. https://doi.org/10.4103/jfmpc.jfmpc_1098_1 9 41. can breast cancer in men be found early? (n.d.). https://www.cancer.org/cancer/breastcancer-in-men/detection-diagnosisstaging/detection.html. retrieved august 1, 2022, from https://www.cancer.org/cancer/breastcancer-in-men/detection-diagnosisstaging/detection.html garza, et al breast cancer in men https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 113 2022, vol. 2 no. s2 106-115 42. chamot, e., & perneger, t. v. (2002). men's and women's knowledge and perceptions of breast cancer and mammography screening. preventive medicine, 34(3), 380–385. https://doi.org/10.1006/pmed.2001.0999 43. midding e, halbach sm, kowalski c, weber r, würstlein r, ernstmann n. men with a "woman's disease": stigmatization of male breast cancer patients-a mixed methods analysis. am j mens health. 2018 nov;12(6):2194-2207. doi: 10.1177/1557988318799025. epub 2018 sep 15. pmid: 30222029; pmcid: pmc6199445. 44. breast cancer screening: paternalistic, sexist, say critics medscape apr 25, 2012 45. nguyen t, s, bauer m, maass n, kaduszkiewicz h: living with male breast cancer: a qualitative study of men’s experiences and care needs. breast care 2020; 15:6-13. doi: 10.1159/000501542 46. fors, m. (2020, june 10). identifying the needs of men with breast cancer (oncology nursing news, ed.) [review of identifying the needs of men with breast cancer]. oncnursingnews.com; oncology nursing news. https://www.oncnursingnews.com/view/iden tifying-the-needs-of-men-with-breast-cancer 47. trusson d, quincey k. breast cancer and hair loss: experiential similarities and differences in men's and women's narratives. cancer nurs. 2021 jan/feb;44(1):62-70. doi: 10.1097/ncc.0000000000000745. pmid: 31567492 48. breast cancer. (2022, july 27). male breast cancer. breastcancer.org. retrieved august 3, 2022, from https://www.breastcancer.org/types/malebreast-cancer#section-risk-factors-for-malebreast-cancer. 49. medscape. (2022, february 11). breast cancer in men: overview of male breast cancer, etiology, diagnosis. medscape reference. retrieved august 3, 2022, from https://emedicine.medscape.com/article/195 4174-overview 50. breast cancer. (2019, september 23). men with breast cancer have lower survival rates than women. breastcancer.org. retrieved august 3, 2022, from https://www.breastcancer.org/researchnews/men-with-bc-have-lower-survivalrates 51. shah, t., shah, n., vijay, d. g., patel, b., & patel, s. (2019). male breast cancer: current trends—a tertiary care centre experience. indian journal of surgical oncology, 11(1), 7–11. https://doi.org/10.1007/s13193-01901021-5 52. andrykowski m. a. (2012). physical and mental health status and health behaviors in male breast cancer survivors: a national, population-based, case-control study. psycho-oncology, 21(9), 927–934. https://doi.org/10.1002/pon.2001 53. men with breast cancer have lower survival rates than women. (2020, june 25). breastcancer.org. https://www.breastcancer.org/researchnews/men-with-bc-have-lower-survivalrates garza, et al breast cancer in men https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 114 2022, vol. 2 no. s2 106-115 table 1: risk factors for male breast cancer 28 centers of disease control and prevention. (n.d.). breast cancer in men. cdc. retrieved august 2, 2022, from https://www.cdc.gov/cancer/breast/men/ 29american cancer society. “risk factors for breast cancer in men what causes breast cancer in men? can breast cancer in men be prevented?” american cancer society, 27 april 2018, https://www.cancer.org/cancer/breast-cancer-in-men/causes-risks-prevention/risk-factors.html. accessed 2 august 2022 strong risk factors moderate risk factors weak risk factors family history of breast cancer. having breast cancer family members increases the risk of developing this disease. genetic mutation. men who inherit brca2 have a 6% greater risk of breast cancer liver disease. male breast cancer risk increases as scarring of the liver lowers androgen levels and raises estrogen levels. testicle disease or surgery. having orchitis, an injury, swelling, or surgery to remove a testicle has a higher risk of breast cancer. klinefelter’s syndrome. a rare genetic condition that has caused the male to have an extra x chromosome. exposure to estrogen. hormone therapy for prostate cancer can increase your risk of breast cancer older age. as you get older the risk of having breast cancer increases. male breast cancer is often diagnosed in their early 60s. radiation therapy treatment. men who are treated for cancer in the chest may be at increased risk of developing breast cancer. the hormonal changes that occur after radiation treatment in men can cause abnormalities in breast tissue obesity. men who have obesity or are overweight are mostly likely to get breast cancer hormone therapy treatment. prostate cancer treatment with drugs containing estrogen increases men’s breast cancer risk. alcohol. drinking alcohol is linked to an increased risk of breast cancer. this may be due to the effects of heavy drinking on the liver, which can influence how hormone receptors work in the body. garza, et al breast cancer in men https://doi.org/10.47488/dhrp.v2is2.71 dhr proceedings ǀ http://dhrproceedings.org 115 2022, vol. 2 no. s2 106-115 table 2: classes of male breast cancer genetic susceptibility and comparison of their different features high penetrance moderate penetrance low penetrance genes brca2, brca1 chek2, palb2 2q35, 6q25.1 (esr1), 10q21.2, 11q13.3, 12p11.22, 14q24 (rad51l1) and 16q12.1 (tox3) population frequency <0.1% maf 1% maf >10% cancer risk (odds ratio) >10.0 >2.0 0.76–1.57 functional effect direct effect of mutation direct effect of variant direct effect of variant; linkage disequilibrium with causal variants strategy for identification resequencing of candidate genes resequencing of candidate genes case–control studies; genome-wide association study (gwas) 31 p. rizzolo, v. silvestri, s. tommasi, r. pinto, k. danza, m. falchetti, m. gulino, p. frati, l. ottini,male breast cancer: genetics, epigenetics, and ethical aspects, annals of oncology,volume24,supplement8,2013,pagesviii75-viii82,issn09237534,https://doi.org/10.1093/annonc/mdt316.(https://www.sciencedirect.com/science/article/pii/s0923753419315996) figure 1. regularity of gene mutations in mbc tumors and bc (breast cancer) and the cancer genome atlas genetics program (tcga) samples 32 campos fab, rouleau e, torrezan gt, carraro dm, casali da rocha jc, mantovani hk, da silva lr, osório cabt, moraes sanches s, caputo sm, santana dos santos e. genetic landscape of male breast cancer. cancers (basel). 2021 jul 15;13(14):3535. doi: 10.3390/cancers13143535. pmid: 34298749; pmcid: pmc8305894 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.86 dhr proceedings ǀ http://dhrproceedings.org 28 2023, vol. 2 no. s2 28-32 commentary what environmental factors increase the risk of cerebral palsy in unborn children? alexa raquel lopez1,2, jayden manzanares1,3, amani nguma1,4, mahir alam1,4, victoria anette garcia1,4, juan gutierrez1,5, savannah rivera1,5, alexis blanco1,5, sophia mireles1,6, saachi grover1,7, aolani garza-gonzalez1,8 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 achieve early college high school, mcallen, tx 3 idea tres lagos, mcallen, tx 4 mcallen memorial high school, mcallen, tx 5 santa maria high school, santa maria, tx 6 south texas isd science academy, mercedes, tx 7 the field school, washington, dc 8 thelma r. salinas stem early college high school, la joya, tx received: june 29, 2023 accepted for publication: september 1, 2023 published: november 16, 2023 introduction approximately 1 in 345 children are diagnosed with cerebral palsy and 85%-90% of these cases are congenital.1 cerebral palsy is a complex and multifaceted neurological disorder that has significant implications for individuals and their families. there are a wide range of risk factors that can contribute to the development of cerebral palsy, including environmental factors that can increase the risk of cerebral palsy in the fetus. some of these risk factors are modifiable and can reduce the risk of cerebral palsy. by understanding the intricacies of cerebral palsy, we can contribute not only to medical advancements but also to improving the quality of life for those affected. what is cerebral palsy? cerebral palsy is a motor disability that affects both brain development and muscle movement and is caused by brain damage which results from both physical complications and chemical impediment of the gestational process.2 children affected by cerebral palsy are very limited in mobility. compared to other kids’ abilities, children with cerebral palsy have an impairment of various physical and motor skills. consequently, this can cause them to be prone to mental health conditions. almost half (46%) of children with cerebral palsy have reported anxiety and depression, amongst other conditions.3 symptoms of cerebral palsy can range from minor to severe. while cerebral palsy is not a progressive disorder, these symptoms have the potential to change over time, making child development strenuous and burdensome.2 maternal diet and medication risk for cerebral palsy being cautious of what a mother ingests during pregnancy is crucial to the health of her baby. studies have shown that certain diets and medications can have a big impact on an infant's brain development and can increase the risk for cerebral palsy.4 medications such as opioids and antibiotics should be used with caution.5 an example of these mediations is betamethasone. betamethasone is a drug given to pregnant mothers who are at risk of giving birth prematurely. however, administering more than one dose has been proven to cause damage to the white matter of the fetus’s brain.6 another drug that many pregnant mothers take that could cause cerebral special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.86 dhr proceedings ǀ http://dhrproceedings.org 29 2023, vol. 2 no. s2 28-32 damage in the fetus is pitocin. pitocin is a drug given to mothers in labor to cause uterine contractions and speed up the birthing process. however, if given an incorrect dose, the contractions can become too powerful and cut off oxygen for the fetus, leading to brain trauma-induced cerebral palsy.7 diets and caloric intake have also been associated with gestational risk, with one study demonstrating how maternal obesity has an impact on infant health.8 alongside some drugs, certain vitamins and supplements have proven to increase the risk of a fetus developing cerebral palsy.9 protective nutrients such as those found in fish and folate should be considered for infant health and to decrease the risk for cerebral palsy.9 other nutrients, however, such as those found in meat, are considered a potential risk for cerebral palsy.10 a study in norway and denmark looking at maternal intake found that mothers who supplemented with folate had a lower association for cerebral palsy.8,9 among births where the mother was diagnosed with obesity, her child had a higher risk of cerebral palsy. studies show that out of 6.2 million births, 67,200 (1.1%) of recorded mothers had obesity and 8,798 (0.14%) of children born had cerebral palsy.11 keeping good nutrition during pregnancy can lower a child’s risk of cerebral palsy. physicians have recommended for pregnant women to avoid taking vitamin a during pregnancy, especially in the form of topical retinoids and other acne products. in fact, doctors always ask patients if they are pregnant before prescribing vitamin a based acne products to ensure that no harm is caused.12 studies have shown that mothers who have used retinoids and other vitamin a products during pregnancy have birthed babies with fetal retinoid syndrome and other neurodevelopmental impairments leading to cerebral palsy. adequate maternal nutrition and health status is important for the growing fetus. if good nutrition is not present during pregnancy, it can lead to long term effects for both the mother and the baby. maternal infection infections can cause the mother’s immune system to increase the number of proteins called cytokines. cytokines circulate in the blood and brain of the child, which can cause inflammation. cytokines are signaled to repair and remodel tissue after certain cellular behavior. when cytokines bind to the receptors, they introduce hundreds of interferon (ifns) and stimulated genes (isgs).13 these genes assist in the restriction of infections in the body. there are three types of ifns, and they all have different functions and targets based on the expressions of the receptors. during pregnancy, the ifns are employed and used in a defense against pathogens. the alterations that the ifns induce can lead to pregnancy complications and congenital abnormalities. since the influx of cytokines can cause congenital disorders, it can be concluded that ifns pose a risk for cerebral palsy.14 the most common congenital infection is cytomegalovirus (cmv), which is found in 1% of live births.15 cmv has been linked as a risk factor for the development of cerebral palsy. one study explored the relationship between the level of cmv infection and the developmental skills in children with cerebral palsy. not only were a larger number of copies of cmv found in mothers of children with cerebral palsy compared to the control group, but decreased motor function and increased chance of spastic quadriplegia were also found throughout the group of cerebral palsy children with mothers of higher levels of cmv during pregnancy.16 although no relation was found between abnormalities of brain tissues and the amount of cmv in mothers, this study still supports the idea that cmv is a risk factor for cerebral palsy and the level of motor development the child will have. chorioamnionitis has also been linked to cerebral palsy. it is an infection of the placenta and amniotic fluid causing inflammation.17 a case study of 231,582 infants with either spastic or dyskinetic cerebral palsy and a control group of children without cerebral palsy was conducted to determine if chorioamnionitis increases the risk of developing cerebral palsy. fourteen percent of cases with cerebral palsy were diagnosed with chorioamnionitis, while only 4% of the control group were diagnosed with it. other conditions found through logistic regression that may lead to cerebral palsy were intrauterine growth restriction and nulliparity.18 another study examined the relationship between chorioamnionitis, extraamniotic infections, and the risk of cerebral palsy in children. californian births between 1991 and 2001 with maternal hospital diagnoses of intra and extra amniotic infections up to 12 months before birth were studied. it was determined that an infection diagnosis was more common in mothers of children with cerebral palsy. out of the 8,473 children with cerebral palsy, 7.6% of their mothers had a chorioamnionitis diagnosis, compared to only 2.0% of mothers of children without cerebral palsy.19 the correlation between chorioamnionitis and cerebral palsy supports the claim that the amniotic inflammation from chorioamnionitis has an increased chance of damaging the fetal brain and leading to cerebral palsy. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.86 dhr proceedings ǀ http://dhrproceedings.org 30 2023, vol. 2 no. s2 28-32 in addition to cmv and chorioamnionitis, maternal urinary tract infections have also been found to be a potential risk factor in children developing cerebral palsy.20 a study done amongst 112 mothers of children with cerebral palsy and a control group of 153 mothers of children without cerebral palsy found that 17.9% of mothers of children with cerebral palsy had a uti, while only 5.2% of mothers in the control group had utis during pregnancy.21 at the time of the study, not much previous research had identified a relationship between maternal utis and the risk for cerebral palsy, making both this study and polivka et al., 1993 one of the first to report detecting an association between utis and cerebral palsy. another study found a similar relationship between mothers with utis and the birth of children with cerebral palsy. an analysis of 8,473 mothers of infants with cerebral palsy found that 5.2% had been diagnosed with a uti, compared to 3.1% of 6,010,031 mothers of children without cerebral palsy.22 it is important that healthcare professionals aim to educate pregnant patients and improve patient care to prevent such a common infection like a uti from occurring, thus preventing harm to fetal brain development and preventing cerebral palsy. chemicals and toxicity interactions between environmental chemicals and fetal development may also increase the risk of cerebral palsy and create hormonal imbalances.23 methylmercury, a teratogen found in the bodies of fish and sea-dwelling consumers, can be spread through the biomagnification of food chains.24 the concentration of methylmercury increases directly with the trophic level, meaning humans who consume seafood are exposed to the chemical. methylmercury exposure would not be problematic unless consumed in large amounts to the average person, however, to the fetus, it is more susceptible to the effects of toxic chemicals and teratogens.25 cerebral palsy is one of the various malformations caused by developmental impairment associated with methylmercury exposure. in areas like the great lakes, there have been higher incidences of cerebral palsy hospitalization, indicating a correlation between seafood consumption in an area known for high methylmercury levels and the occurrence of cerebral palsy.26 pesticides are one of the most acknowledged causes for endocrine disruption in humans.27 of the various effects on the human body, disruptions in the fetus during gestation have been related to proximity of agricultural areas in which pesticides were used. in multiple studies with thousands of controls, mothers who resided near agricultural operations were reported to have higher incidence of cerebral palsy.28 although the knowledge of lead’s neurodegenerative effects is widely recognized (for example, it’s phasing out of gasoline as an engine stabilizer and as an ingredient in paint), industrial factors as well as the removal of lead-containing objects still allow lead to be a serious problem in the neurodevelopment of children.29 through the removal of paint that was originally applied with lead as an ingredient, as well as the demolition of leadcontaining buildings, lead dust can be released into soils, recreational products, and water. mothers near mining operations involving the harvesting of lead can also put children at risk for stunted neurodevelopment, as well as higher lead absorption.30 in areas of limited access to drinking water regulation, studies have shown that children with cerebral palsy have higher concentrations of lead.31 conclusion research on the relationship between environmental factors and cerebral palsy has elucidated various factors that can contribute to the increased risk of cerebral palsy. these factors include being exposed to an illness while pregnant, taking certain medication, and being exposed to certain toxins. more importantly, some of these risk factors are modifiable and it is crucial for expecting mothers to limit their interaction with these risk factors. by taking action to lessen exposure to these environmental factors, we can contribute to the prevention of cerebral palsy. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.86 dhr proceedings ǀ http://dhrproceedings.org 31 2023, vol. 2 no. s2 28-32 references 1. data and statistics for cerebral palsy (2022) centers for disease control and prevention. available at: https://www.cdc.gov/ncbddd/cp/data.html (accessed: 28 june 2023). 2. what is cerebral palsy? (2022) centers for disease control and prevention. available at: https://www.cdc.gov/ncbddd/cp/facts.html#: ~:text=cp%20is%20the%20most%20comm on,control%20his%20or%20her%20muscles . (accessed: 28 june 2023). 3. cerebral palsy & mental health (2022) cerebral palsy research network. available at: https://cprn.org/cerebral-palsy-mentalhealth/ (accessed: 28 june 2023). 4. ross, e.j. et al. (2015) developmental consequences of fetal exposure to drugs: what we know and what we still must learn, neuropsychopharmacology: official publication of the american college of neuropsychopharmacology. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc4262892/ (accessed: 28 june 2023). 5. dathe, k. and schaefer, c. (2019) the use of medication in pregnancy, deutsches arzteblatt international. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc6935972/ (accessed: 28 june 2023). 6. sutherland, a.e. et al. (2020) does antenatal betamethasone alter white matter brain development in growth restricted fetal sheep?, frontiers in cellular neuroscience. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc7203345/ (accessed: 28 june 2023). 7. page medically reviewed and edited by pierrette mimi poinsett and dr. poinsett is a board certified pediatrician. she is a graduate of the university of chicago (2022) pitocin errors and cerebral palsy: medical malpractice, cerebral palsy guidance. available at: https://www.cerebralpalsyguidance.com/cer ebral-palsy/causes/pitocin-errors/ (accessed: 28 june 2023). 8. marshall, n.e. et al. (2022) the importance of nutrition in pregnancy and lactation: lifelong consequences, american journal of obstetrics and gynecology. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc9182711/ (accessed: 28 june 2023). 9. groot, j. et al. (2022) maternal intake of folate during pregnancy and risk of cerebral palsy in the moband-cp cohort, the american journal of clinical nutrition. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc8827124/ (accessed: 28 june 2023). 10. giromini, c. and givens, d.i. (2022) benefits and risks associated with meat consumption during key life processes and in relation to the risk of chronic diseases, foods (basel, switzerland). available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc9318327/ (accessed: 28 june 2023). 11. crisham janik, m.d. et al. (2013) maternal diagnosis of obesity and risk of cerebral palsy in the child, the journal of pediatrics. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc3812421/ (accessed: 28 june 2023). 12. storymd (no date) what is fetal retinoid syndrome? storymd.com. available at: https://storymd.com/journal/7m7aaa2fpmpregnancy-andmedicines/page/g65990777y-what-is-fetalretinoid-syndrome (accessed: 28 june 2023). 13. marret, s., vanhulle, c., & laquerrière, a. (2013b). pathophysiology of cerebral palsy. in handbook of clinical neurology (pp. 169– 176). elsevier bv. doi: https://doi.org/10.1016/b978-0-444-528919.00016-6 14. grether, j. k., nelson, k. m., dambrosia, j. m., & phillips, t. m. (1999b). interferons and cerebral palsy. the journal of pediatrics, 134(3), 324–332. doi: https://doi.org/10.1016/s00223476(99)70458-0 15. cmv fact sheet for pregnant women and parents |cdc. (n.d.-b). available at: https://www.cdc.gov/cmv/factsheets/parents-pregnantwomen.html#:~:text=you%20may%20be% 20able%20to%20lessen%20your%20risk%2 0of%20getting,or%20cups%20with%20a%2 0child. 16. xu, h. e., zhang, l., xuan, x., zhu, m., tang, j., & zhao, x. s. (2020c). intrauterine cytomegalovirus infection: a possible risk for cerebral palsy and related to its clinical features, neuroimaging findings: a retrospective study. bmc pediatrics, 20(1). available at: https://doi.org/10.1186/s12887020-02449-3 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.86 dhr proceedings ǀ http://dhrproceedings.org 32 2023, vol. 2 no. s2 28-32 17. shi z, ma l, luo k, et al. chorioamnionitis in the development of cerebral palsy: a meta-analysis and systematic review. 2017;139(6). available at: https://pubmed.ncbi.nlm.nih.gov/28814548/ 18. wu yw. chorioamnionitis and cerebral palsy in term and near-term infants. jama. 2003;290(20):2677. doi: https://doi.org/10.1001/jama.290.20.2677 19. bear jj, wu yw. maternal infections during pregnancy and cerebral palsy in the child. pediatric neurology. 2016; 57:74-79. available at: https://pubmed.ncbi.nlm.nih.gov/26857522/ 20. cerebral palsy from urinary tract infection (uti) | michigan cerebral palsy attorneys. (2019, february 18). available at: https://www.michigancerebralpalsyattorneys .com/causes-and-risk-factors-of-cerebralpalsy/maternal-health/cerebral-palsyurinary-tract-infection-uti/ 21. polivka, b. j., nickel, j. t., & wilkins, j. w. (1997). urinary tract infection during pregnancy: a risk factor for cerebral palsy? journal of obstetric, gynecologic, & neonatal nursing, 26(4), 405–413. doi: https://doi.org/10.1111/j.15526909.1997.tb02722.x 22. bear, j. j., & wu, y. w. (2016b). maternal infections during pregnancy and cerebral palsy in the child. pediatric neurology, 57, 74–79. doi: https://doi.org/10.1016/j.pediatrneurol.2015. 12.018 23. what are the risk factors for cerebral palsy? (no date) eunice kennedy shriver national institute of child health and human development. available at: https://www.nichd.nih.gov/health/topics/cer ebral-palsy/conditioninfo/risk-factors (accessed: 28 june 2023). 24. canada, e. and c.c. (2013) government of canada, canada.ca. available at: https://www.canada.ca/en/environmentclimate-change/services/pollutants/mercuryenvironment/health-concerns/foodchain.html (accessed: 28 june 2023). 25. harding, g., dalziel, j. and vass, p. (2018) bioaccumulation of methylmercury within the marine food web of the outer bay of fundy, gulf of maine, plos one. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc6047777/ (accessed: 28 june 2023). 26. myers gj, davidson pw. does methylmercury have a role in causing developmental disabilities in children? environmental health perspectives. 2000;108(suppl 3):413-420. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc1637830/ 27. mnif w, hassine aih, bouaziz a, bartegi a, thomas o, roig b. effect of endocrine disruptor pesticides: a review. international journal of environmental research and public health. 2011;8(6):2265-2303. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc3138025/ 28. liew z, ehrenstein von, ling c, et al. ambient exposure to agricultural pesticides during pregnancy and risk of cerebral palsy: a population-based study in california. 2020;8(3):52-52. available at: https://pubmed.ncbi.nlm.nih.gov/32751992/ 29. wilson n, horrocks j. lessons from the removal of lead from gasoline for controlling other environmental pollutants: a case study from new zealand. environmental health. 2008;7(1). available at: https://ehjournal.biomedcentral.com/articles/ 10.1186/1476-069x-7-1 30. choudhari r, sathwara ng, shivgotra vk, et al. study of lead exposure to children residing near a lead–zinc mine. indian journal of occupational and environmental medicine. 2010;14(2):58-62. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc2992867/ 31. bansal n, aggarwal a, faridi mma, sharma t, baneerjee bd. association of lead levels and cerebral palsy. global pediatric health. 2017; 4:2333794x1769668. available at: https://www.ncbi.nlm.nih.gov/pmc/articles/p mc5406142/ special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.96 dhr proceedings ǀ http://dhrproceedings.org 79 2023, vol. 2 no. s2 79-86 commentary benefits of glp-1 agonists julian ruben alaniz1,2, juan avila1,4, klarissa renee cantu1,2, joe frank cruz1,4, hector de la cruz1,5, aileen jaramillo1,5, fabiola lopez sanchez1,3, gia pena1,4, alan salinas1,4, sadie faye viera1,2, karely cantu1,6, jacob ryan garcia1,2 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 benavides secondary school, benavides, tx 3 raymond & tirza martin high school, laredo, tx 4 edinburg north high school, edinburg, tx 5 zapata high school, zapata, tx 6 mcallen high school, mcallen, tx received: november 1, 2023 accepted for publication: november 3, 2023 published: november 16, 2023 introduction glucagon-like peptide-1 (glp-1) agonists, are a class of medications which are utilized in the treatment of type 2 diabetes, and obesity. the body naturally produces the hormone glp-1 when the gut is stimulated by the consumption of food.1 type 2 diabetes can cause many health issues such as heart disease, foot problems and chronic kidney disease (ckd).2 glp-1 drugs work by mimicking the glp-1 hormone that the body would naturally produce in three ways. first, stimulates release of insulin from the pancreas after eating. second, inhibits the release of a hormone called glucagon, which stimulates the liver into releasing sugars that have been stored in the bloodstream. third, it slows absorption of glucose into the blood by reducing the speed at which the stomach empties after consuming food, which makes you feel satisfied, extending the sensation of feeling full after eating.3 these effects combine, keeping your blood sugars down, supporting other benefits of taking a glp-1 drug. metabolic benefits metabolism is a balancing act involving two kinds of activities that go on at the same time. the first is a build-up of body tissue and energy stores, known as anabolism. the second activity consists of storing energy to get more fuel for the body's functions, known as catabolism. metabolism is focused on building and storing. it supports the growth of new cells, storing all energy for future use. in anabolism, small molecules transform into larger, more complex molecules of carbohydrates, protein, and fat. the use of glp-1ras (glucagon-like peptide1 receptor agonists) has significantly increased cardiovascular activity in patients with type 2 diabetes. this new antidiabetic drug class has decreased cardiovascular mortality and promotes lifespan. some benefits include decreased blood pressure values, weight reduction, and improvement of dyslipidemia (abnormal amount of lipids in the blood), improvements of blood circulation potentially increasing nitric oxide levels inhibiting clotting factors, such as thromboxane a2, selectins, and vascular cell adhesion molecules.2 reducing hepatic lipogenesis and augmenting mitochondrial oxidative capacity increases energy expenditure and brown adipose tissue. a study done by holst jj showed that tirzepatide dose-dependently lowered triglyceride, apoc-iii, and apob levels over time as well as reduced the number of large triglyceride-rich lipoprotein particles and small low-density lipoprotein particles compared to dulaglutide and/or placebo. these findings indicate increased insulin sensitivity and a shift toward a less atherogenic lipoprotein profile in subjects with t2d treated with tirzepatide, with potential implications for cardiovascular safety. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.96 dhr proceedings ǀ http://dhrproceedings.org 80 2023, vol. 2 no. s2 79-86 cardiovascular benefits glucagon-like peptide-1(glp-1) has been linked to being beneficial in aiding the improvement in the human body. one of those benefits is helping cardiovascular health. the glp-1 receptor has been found in all four chambers of the heart. it has been shown that glp-1 is favorable in lowering triglycerides and cholesterol in the blood.3 the wide variety of benefits have been shown to improve the quality of life of those with and without diabetes, each with varying cardiovascular diseases, killing thousands of people every year. cardiovascular disease (cvd) or heart disease, continues to be the predominant cause of mortality in the united states. it claimed the lives of 928,741 individuals in 2020 and took approximately 695,000 lives in 2021, representing 1 out of every five deaths nationwide, this computes to one death every 33 seconds.4 cardiovascular disease affects all ethnicities, but some groups are more at risk than others, such as african americans, and hispanic americans are more likely to develop cvd than caucasians. both men and women are at risk of cvd but men can develop it at a younger age than women. however, for women, the risk of cvd increases after menopause.5 moreover, the mortality rate of men and women who succumb to cardiovascular disease is significantly correlated to the high cost of treatment for these diseases. finding alternative treatments for cardiovascular disease, such as the glp-1, can aid clinicians in improving patients’ health and relieving the potential financial burden placed on a patient and their overall quality of life. this combined with healthy lifestyle choices can further improve the patient’s health outcome resulting in a change in the condition of the patient when they finish their treatment. the agonism of the receptor has been shown to improve the endothelial function. the theoretical mechanisms of the anti-atherosclerotic effects of the agents would change the amount of force the heart would have to exert to pump blood throughout the cardiovascular system. clinical studies have shown a reduction in intracellular calcium overload of high stress and glucose-induced apoptosis. this means that patients would have a reduced risk of heart related conditions and diseases. it does not have an effect on hospitalization admission based on heart complications. overall, this evidence suggests that glucagon-like peptide-1 (glp-1) can be an effective treatment to improve cardiovascular health. neurological benefits the nervous system is one of the most important systems in the human body due to its many functions such as sending signals to the rest of the body to maintain homeostasis. the benefits of glucagon-like peptide-1 on the nervous system are numerous including, but not limited to, prevention of conditions such as alzheimer’s, anti-addictive properties, and affects the relationship that the body has with food. alzheimer's alzheimer’s is a brain disorder in which neurofibrils, which are responsible for sending messages in the brain, get tangled due to an overproduction of beta-amyloid peptides.10 it is usually characterized by the loss of memory that people experience. after studies conducted on male rats, it was determined that glp-1 improved spatial memory in mice.10 spatial means relating to space in an environment; spatial memory functions as a remembrance of objects in relation to a room as well as correlating objects to others based on function. this means that administration of a glp-1 agonist could potentially improve memory function in persons with alzheimer’s disorder. moreover, glp-1 agonist liraglutide has been shown to cross the hematoencephalic barrier where, besides the glp-1 receptor activation, it has pleiotropic neuroprotective effects which could represent a viable use for the treatment of neurodegenerative diseases and after intracerebral hemorrhage. the regulation of glp-1 agonists indirectly nourishes cells through the process of glycolysis; models of astrocytes in persons with alzheimer’s disease show that they are lacking this process which is why they develop the disease in the first place.10 anti-addictive properties there are copious amounts of research into the effect that glp-1 agonists have on addictions such as alcohol use disorder, or aud, primarily done on non-human mammals. the glp-1 agonists that have shown the most promising results are exenatide and liraglutide. a human clinical trial, which was terminated due to the then ongoing covid-19 pandemic, on the effects of exenatide on substance use disorders, such as alcohol and nicotine, has shown promising results.11 some of the results that could be analyzed showed that when exposed to glp-1 agonists such as exenatide, dulaglutide, and liraglutide many subjects in the clinical trial reported a decrease special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.96 dhr proceedings ǀ http://dhrproceedings.org 81 2023, vol. 2 no. s2 79-86 in their use of their preferred substance to abuse of.11 the results from recent clinical trials show favorable results against substances such as cocaine and alcohol. however, most of the studies that have been conducted are either ongoing or are not conducted on human subjects, which limits the availability of information. relationship with food the human body is constantly working to maintain homeostasis through the different body systems. in order to maintain proper levels of nutrients and energy, the nervous system releases hormones that make a person feel ‘hunger’ so that food can be ingested. once there are enough nutrients or food to be digested there is a decrease in hormone levels which leads to someone feeling ‘full’ or satiated.12 one of the peptide hormones that is released is glp-1 agonists. this is why this peptide is normally recommended for obesity and weight loss. glp-1 agonists mobilize the afferent vagus nerve in order to release the nucleus tractus solitarii preproglucagon (nts ppg) and nucleus tractus solitarii dopamine beta-hydroxylase (nts dbh).12 nts ppg is used in order to generate major hormones and nts dbh starts the process of altering dopamine into norepinephrine. norepinephrine is used to maintain proper blood levels in the body. this in turn reduces the quantity of food consumption as well as meal portions. endocrine benefits the endocrine system is made up of the hypothalamus, pituitary gland, thyroid gland, adrenal glands, parathyroid glands, pineal gland, thymus, and pancreas. it has important functions like releasing hormones that can control metabolism, growth, reproduction, and sleep.13 yet, its interaction with the glp-1 hormone has shown to have benefits including weight loss, increased fertility in women with polycystic ovary syndrome (pcos), and strengthening the immune system against diseases. reduced risk of cancer the endocrine system is intricately linked with other systems of the body, including the nervous and immune systems. for example, the thymus is an organ associated with the immune system that helps fight off infections by controlling white blood cells, while the brain, specifically the hypothalamus, maintains homeostasis by sending a signal to the pituitary gland to correct that abnormality.14 as a result of this homeostatic loop, the pituitary gland releases hormones that cause the body’s temperature to rise to fight off the infection. antigens entering the body though the environment or via vaccines, trigger a response by immune cells by activating “natural killer” (nk) cells. these play the role of a natural vaccine that is produced by the body’s immune system, without the prior introduction of foreign antigens to trigger that immune response.15 they do this by spotting and destroying mutated cells throughout the body, in effect also helping to prevent the spread of cancer cells. in this scenario, obesity can be problematic by disrupting these cells, putting overweight individuals at higher risk of cancer. although glp-1 drugs are traditionally prescribed to people with type 2 diabetes, it has also been shown to cause weight loss, which has a positive effect on patients with obesity by restoring “natural killer” (nk) cells that improve the immune system. in a study done at maynooth university, researchers followed the progress of twenty obese participants who were prescribed a semaglutide (glp-1) once weekly for over six months. the results of this study found that these patients had improved nk cell function.16 separate from just weight loss, glp-1 agonists have preventative benefits by helping to reduce the risk of cancer, one of the many detrimental complications associated with obesity. increased fertility obesity can lead to many other health complications, including its association with polycystic ovary syndrome (pcos). polycystic ovary syndrome is an endocrine disorder where the hormone androgen is secreted excessively, producing cysts within the ovaries. pcos affects females and can cause infertility, weight gain, insulin resistance, and heart issues, among other medical difficulties.17 insulin resistance in some women with pcos puts them at higher risk for developing type 2 diabetes due to the body not being able to use the insulin produced by the pancreas effectively. the etiology behind this is complex, with one reason thought to be related to pancreatic beta cell dysfunction, but a combination of many genetic factors and metabolic processes in the body are thought to be involved.18 fairly new, but limited, shows that glp-1 agonist semaglutide aids in not only weight reduction in pcos patients but also is correlated with the reproductive system.19 this by extension increases fertility since it helps reduce inflammation and fibrosis in the ovaries.19 although limited, this research is an encouraging start that proves more studies are needed to investigate glp-1 and how it has far-reaching benefits beyond the scope of treating diabetes and can special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.96 dhr proceedings ǀ http://dhrproceedings.org 82 2023, vol. 2 no. s2 79-86 be used to treat other complex endocrine disorders such as pcos as well. reduction of diabetes risk due to the necessity for the normal developmental process and maturity of vertebrates as well as its ability to control metabolism, growth, and development, the thyroid is a significant gland in the system known as the endocrine system. thyroid hormones exhibit a variety of effects on the heart, muscles, and digestive system. the rate of heartbeat and cardiac contraction is increased by the thyroid, which enhances both the systolic and diastolic activity of the heart. this prolongs life expectancy and lowers the risk of myocardial infarction while also enhancing the quality of life.20 a main condition people get from their endocrine system tends to be diabetes. diabetes comes in two different types: the likelihood of acquiring type 1 diabetes is increased by geography, age, genetics, and family history. with type 2 diabetes, on the other hand, the human body either becomes resistant to insulin or stops generating sufficient insulin; another difference is that type 2 diabetes develops mostly through genetics, advanced age, sedentary lifestyle, bad dietary lifestyle, and obesity. despite the fact that it might seem like a person has no symptoms or visible indicators of the condition, it may take weeks, months, or even years before one can be certain that they have type 1 diabetes. it can happen as a result of an autoimmune reaction in which beta cells assault the pancreas and destroy insulin. since human bodies convert food into glucose after eating and release it into the blood, insulin is crucial to the human body. then, insulin aids in transferring the glucose from the blood into cells, where it can be used as an energy source now or in the future. patients with type 1 diabetes do not produce enough or any insulin, which prevents the glucose from entering the cells and accumulating in the bloodstream rendering the energy useless. since insulin is so important to humans, type 1 diabetes's lack of it disrupts the entire process of how humans obtain energy. many glp-1 users report feeling more invigorated after taking the drug; this experience indicates that the drug is working as intended to increase glucose in human bodies. conversely, type 2 diabetes has an adverse effect on a number of important organs, the kidneys, blood vessels, nerves, eyes, and heart.20 additionally, risk factors for diabetes may raise the chance of other serious illnesses. controlling blood sugar and managing diabetes can reduce the risk of these problems and other illnesses. despite the many risk factors, there are several approaches to fight this illness, including raising the standard of living, more physical activity, and the intake of semaglutide. semaglutide is prescribed to some individuals who are at risk of getting diabetes because it aids in weight loss, which lowers the risk of developing diabetes. when blood sugar levels start to rise after eating, these medications may also encourage the body to produce more insulin. the extra insulin helps lower blood sugar levels. lower blood sugar levels can aid in the management of type 2 diabetes.21 benefits for the liver the liver is both an organ and a gland that is roughly the size of a football and the color is reddishbrown, however, the size changes according to a person’s weight and height. the liver is a vital organ that carries out numerous tasks required for life support. since it produces proteins and hormones that are required by other bodily components, this makes it a gland. the liver is the biggest internal organ, weighing about three pounds in an adult. the liver is located in the upper abdomen and is responsible for several biological processes such as removing all toxins from the body's blood, helping regulate blood sugar, and helping blood clotting.30 fatty liver disease is one of the most common diseases that can harm the liver. obesity, diabetes, and heavy alcohol consumption are among the components that can lead to fatty liver. toxin-like effects of fatty liver can cause inflammation in the liver cells and lead to the development of cirrhosis. anyone who suffers from liver disease or in particular “non-alcoholic fatty-liver disease” can get benefits from taking glp-1 agonists. the fatty liver disease is a disease that builds up fat around the liver which causes several health issues within the whole body. symptoms of fatty liver disease often include, abdominal pain or a feeling of fullness in the upper right side of the abdomen (belly). nausea, loss of appetite or weight loss. yellowish skin and whites of the eyes (jaundice). swollen abdomen and legs (edema). to diagnose nafld and distinguish between nafl and nash, doctors employ blood testing, imaging tests, and occasionally liver biopsies. for blood testing, you give a blood sample, then send that specimen to a lab. if your blood test results reveal an elevated amount of the liver's enzymes alanine aminotransferase, or alt, and the aminotransferase special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.96 dhr proceedings ǀ http://dhrproceedings.org 83 2023, vol. 2 no. s2 79-86 aspartate (ast), your doctor may assume you have nafld.27 another liver disease is cirrhosis. cirrhosis mainly affects people who are overweight, drink too much alcohol, and have viral hepatitis. fatigue, bruising, bleeding, appetite decrease, nausea, edema, weight loss, rough skin, jaundice, ascites, spider-like blood vessels, red palms, pale fingernails, clubbing, menopause, sex desire, testicular atrophy, gynecomastia, breast enlargement, and fuzziness can all be symptoms of this condition. a previous study observed mice with nash and were given cotadutide which led to improvements in liver histology, including decreases in steatosis, inflammation, and fibrosis.33 this evidence suggests that glp-1 agonists can have a positive effect on liver disease and can directly lower hepatic lipogenesis and increase mitochondrial oxidative capability while also indirectly improving the clinical components of nash. glp-1 can enhance liver function, fat content and distribution, and lipid metabolism while lowering the activity of inflammatory cytokines and the signal transduction pathways connected to the hepatocytes which helps the liver decrease the chance of leading to cirrhosis. additionally, since adipose liver poses a risk to life, lowering the fatty tissue, glp-1 can even improve the conditions of fatty liver by reducing steatosis. the liver has repeatedly been reported to be a target for glp-1.31 glp-1 receptor agonists are a new medication that mimics insulin in the human body. they have great effects such as reducing inflammation and improving insulin in the body. this medication is often given by injection and well tolerated, it can also have side effects more commonly as nausea and vomiting.32 gastrointestinal benefits the gastrointestinal (gi) system, also known as the digestive system, is a vital part of the human body that plays an important role in maintaining overall health and well-being. its importance consists of several specific functions that human bodies need, such as digestion, nutrient absorption, gut microbiota balance, and hormone production.38 the gastrointestinal system's proper functioning is essential for the maintenance of good health, immune function, energy production, and overall vitality. any disruptions or disorders in this system can lead to various health issues and impact the body's ability to function correctly, such as a leaky gut affecting gut permeability as well as overall intestinal barrier function. colonic permeability improvement glp-1 may play a role in maintaining the integrity of the gut barrier. this could involve supporting the tight junctions between the cells of the intestinal lining, which prevent the leakage of harmful substances into the bloodstream.35 conditions such as leaky gut, where the lining of the intestines becomes more permeable than normal, allowing substances such as bacteria, toxins, and undigested food particles to leak from the intestines into the bloodstream, can benefit from the administration of the glp-1 agonists.35 the connection between the brain and the gi tract, also known as the blood-brain-barrier, is accessed through a hormone called orexin that is released when administered the glp-1 agonist. although orexin is a naturally produced hormone by the brain’s hypothalamus which controls the body’s energy, appetite, and wakefulness, injection of the glp-1 agonist aids in orexin action potential, which in turn helps support decrease colonic hyperpermeability.34,36 through this action potential, the brain can affect the function of gut microbiota through the autonomic nervous system, by balancing regional gut motility, intestinal transit and secretion, and gut permeability, and potentially through the secretion of hormones, such as epinephrine, that proportionally affect microbial gene expression, which shows promise of aiding in both the symptoms from an individual with leaky gut syndrome, involving stomach bloating and intestinal permeability, as well as someone with irritable bowel syndrome, consisting of bowel inflammation and constipation or diarrhea.37,39 conclusion many individuals considered low-income as the lower-middle class will not have as much availability to medications such as glp-1 agonists due to the cost and the type of health insurance they may have. additionally, while there are many benefits there are also risks that are associated with this medication, however, more research needs to be done to accurately assess how much it can damage a person’s body as well as if the effects are reversible or permanent. moreover, this form of medication used on the human body is recent so the effects that this medication may have as a person’s age progresses is still unknown. furthermore, there is also a judgment that may be passed by society due to the implications that taking medication may have. however, there is also a need for more studies to fully grasp this medication's effect on the entire human body. for instance, there are still special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.96 dhr proceedings ǀ http://dhrproceedings.org 84 2023, vol. 2 no. s2 79-86 organs that need to be studied to successfully record the effects of medications such as glp-1 agonists acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. holst jj. the physiology of glucagon-like peptide 1. physiol rev. 2007 oct;87(4):140939. doi: 10.1152/physrev.00034.2006. pmid: 17928588. 2. iorga ra, bacalbasa n, carsote m, et al. metabolic and cardiovascular benefits of glp-1 agonists, besides the hypoglycemic effect (review). exp ther med. 2020;20(3):2396-2400. doi:10.3892/etm.2020.8714 3. jph;, b. e. h. d. (n.d.). sglt2 inhibitors and glp-1 receptor agonists: established and emerging indications. lancet (london, england). https://pubmed.ncbi.nlm.nih.gov/34216571 4. professional heart daily. professional.heart.org. 5. rm b, pj f, dm k. racial disparities in cardiovascular disease risk: mechanisms of vascular dysfunction. american journal of physiology. heart and circulatory physiology. published october 1, 2019. https://pubmed.ncbi.nlm.nih.gov/31397168/ 6. what is ozempic®? | ozempic® (semaglutide) injection 0.5 mg or 1 mg. www.ozempic.com. https://www.ozempic.com/whyozempic/what-is-ozempic.html 7. ma x, liu z, ilyas i, et al. glp-1 receptor agonists (glp-1ras): cardiovascular actions and therapeutic potential. int j biol sci. 2021;17(8):2050-2068. published 2021 may 11. doi:10.7150/ijbs.59965 8. andrikou, e., tsioufis, c., andrikou, i., leontsinis, i., tousoulis, d., & papanas, n. (2019). glp-1 receptor agonists and cardiovascular outcome trials: an update. hellenic journal of cardiology, 60(6), 347– 351. https://doi.org/10.1016/j.hjc.2018.11.008 9. brothers rm, fadel pj, keller dm. racial disparities in cardiovascular disease risk: mechanisms of vascular dysfunction. am j physiol heart circ physiol. 2019 oct 1;317(4):h777-h789. doi: 10.1152/ajpheart.00126.2019. epub 2019 aug 9. pmid: 31397168; pmcid: pmc6843015. 10. zheng j, xie y, ren l, et al. glp-1 improves the supportive ability of astrocytes to neurons by promoting aerobic glycolysis in alzheimer's disease. mol metab. 2021;47:101180. doi:10.1016/j.molmet.2021.101180 11. klausen mk, thomsen m, wortwein g, fink-jensen a. the role of glucagon-like peptide 1 (glp-1) in addictive disorders. br j pharmacol. 2022;179(4):625-641. doi:10.1111/bph.15677 12. grill hj. a role for glp-1 in treating hyperphagia and obesity. endocrinology. 2020;161(8):bqaa093. doi:10.1210/endocr/bqaa093 13. john hopkins medicine . anatomy of the endocrine system. johns hopkins medicine. published 2019. https://www.hopkinsmedicine.org/health/we llness-and-prevention/anatomy-of-theendocrine-system 14. soto-tinoco e, guerrero-vargas nn, buijs rm. interaction between the hypothalamus and the immune system. exp physiol. 2016;101(12):1463-1471. doi:10.1113/ep085560 15. o'shea d, hogan ae. dysregulation of natural killer cells in obesity. cancers (basel). 2019;11(4):573. published 2019 apr 23. doi:10.3390/cancers11040573 16. conor de barra, khalil m, mat a, et al. glucagon-like peptide-1 therapy in people with obesity restores natural killer cell metabolism and effector function. published online may 9, 2023. https://doi.org/10.1002/oby.23772 17. patel s. polycystic ovary syndrome (pcos), an inflammatory, systemic, lifestyle endocrinopathy. j steroid biochem mol biol. 2018;182:27-36. doi:10.1016/j.jsbmb.2018.04.008 18. ding h, zhang j, zhang f, et al. resistance to the insulin and elevated level of https://pubmed.ncbi.nlm.nih.gov/34216571 https://doi.org/10.1016/j.hjc.2018.11.008 https://www.hopkinsmedicine.org/health/wellness-and-prevention/anatomy-of-the-endocrine-system https://www.hopkinsmedicine.org/health/wellness-and-prevention/anatomy-of-the-endocrine-system https://www.hopkinsmedicine.org/health/wellness-and-prevention/anatomy-of-the-endocrine-system https://doi.org/10.1002/oby.23772 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.96 dhr proceedings ǀ http://dhrproceedings.org 85 2023, vol. 2 no. s2 79-86 androgen: a major cause of polycystic ovary syndrome. front endocrinol (lausanne). 2021;12:741764. published 2021 oct 20. doi:10.3389/fendo.2021.741764ding h, zhang j, zhang f, zhang s, chen x, liang w, xie q. resistance to the insulin and elevated level of androgen: a major cause of polycystic ovary syndrome. front endocrinol (lausanne). 2021 19. jensterle m, janez a, fliers e, devries jh, vrtacnik-bokal e, siegelaar se. the role of glucagon-like peptide-1 in reproduction: from physiology to therapeutic perspective. hum reprod update. 2019;25(4):504-517. doi:10.1093/humupd/dmz019 20. thyroid: what it is, function & problems. cleveland clinic. https://my.clevelandclinic.org/health/body/2 3188-thyroid#:~:text=it 21. cdc. what is type 1 diabetes? centers for disease control and prevention. published march 11, 2022. https://www.cdc.gov/diabetes/basics/whatis-type-1-diabetes.html. 22. mayo clinic. type 2 diabetes. mayo clinic. published march 14, 2023. https://www.mayoclinic.org/diseasesconditions/type-2-diabetes/symptomscauses/syc-20351193. 23. mayo clinic. cirrhosis symptoms and causes. mayo clinic. published february 6, 2021. https://www.mayoclinic.org/diseasesconditions/cirrhosis/symptoms-causes/syc20351487 24. liver: what it does, disorders & symptoms, staying healthy. cleveland clinic. https://my.clevelandclinic.org/health/articles /21481liver#:~:text=the%20liver%20filters%20(cl eans)%20the 25. diagnosis of nafld & nash | niddk. national institute of diabetes and digestive and kidney diseases. https://www.niddk.nih.gov/healthinformation/liver-disease/nafldnash/diagnosis 26. morgan my. the prognosis and outcome of alcoholic liver disease. alcohol and alcoholism (oxford, oxfordshire) supplement. 1994;2:335-343. https://pubmed.ncbi.nlm.nih.gov/8974353/ 27. diagnosis of nafld & nash | niddk. national institute of diabetes and digestive and kidney diseases. https://www.niddk.nih.gov/healthinformation/liver-disease/nafldnash/diagnosis 28. volpe s, lisco g, fanelli m, et al. onceweekly subcutaneous semaglutide improves fatty liver disease in patients with type 2 diabetes: a 52-week prospective real-life study. 2022;14(21):4673-4673. doi:https://doi.org/10.3390/nu14214673 29. tanday n, flatt pr, irwin n. metabolic responses and benefits of glucagon‐like peptide‐1 (glp‐1) receptor ligands. british journal of pharmacology. published online may 10, 2021. doi:https://doi.org/10.1111/bph.15485 30. liver functions, location, anatomy and disease | columbia surgery. columbiasurgery.org. https://columbiasurgery.org/liver/liver-anditsfunctions#:~:text=the%20liver%20and%2 0its%20functions 31. holst jj. the physiology of glucagon-like peptide 1. physiological reviews. 2007;87(4):1409-1439. doi:https://doi.org/10.1152/physrev.00034.2 006 32. zhao x, wang m, wen z, et al. glp-1 receptor agonists: beyond their pancreatic effects. front endocrinol (lausanne). 2021;12:721135. published 2021 aug 23. doi:10.3389/fendo.2021.721135 33. kruepunga n, hakvoort tbm, hikspoors jpjm, köhler se, lamers wh. anatomy of rodent and human livers: what are the differences?. biochim biophys acta mol basis dis. 2019;1865(5):869-878. doi:10.1016/j.bbadis.2018.05.019 34. takuya funayama, tsukasa nozu, masatomo ishioh, et al. centrally administered glp-1 analogue improves intestinal barrier function through the brain orexin and the vagal pathway in rats. 2023;1809:148371-148371. doi:https://doi.org/10.1016/j.brainres.2023.1 48371 35. okumura t, nozu t, ishioh m, et al. oxytocin acts centrally in the brain to improve leaky gut through the vagus nerve and a cannabinoid signaling in rats. physiology & behavior. 2022;254:113914. doi:https://doi.org/10.1016/j.physbeh.2022.1 13914 36. acuna-goycolea c. glucagon-like peptide 1 excites hypocretin/orexin neurons by direct and indirect mechanisms: implications for viscera-mediated arousal. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8564180/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8564180/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8564180/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8564180/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8564180/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8564180/ https://my.clevelandclinic.org/health/body/23188-thyroid#:~:text=it https://my.clevelandclinic.org/health/body/23188-thyroid#:~:text=it https://doi.org/10.3390/nu14214673 https://doi.org/10.1016/j.brainres.2023.148371 https://doi.org/10.1016/j.brainres.2023.148371 https://doi.org/10.1016/j.physbeh.2022.113914 https://doi.org/10.1016/j.physbeh.2022.113914 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.96 dhr proceedings ǀ http://dhrproceedings.org 86 2023, vol. 2 no. s2 79-86 journal of neuroscience. 2004;24(37):81418152. doi:https://doi.org/10.1523/jneurosci.160704.2004 37. martin cr, osadchiy v, kalani a, mayer ea. the brain-gut-microbiome axis. cellular and molecular gastroenterology and hepatology. 2018;6(2):133-148. doi:https://doi.org/10.1016/j.jcmgh.2018.04. 003 38. cleveland clinic. digestive system: function, organs & anatomy. cleveland clinic. published august 9, 2021. https://my.clevelandclinic.org/health/body/7 041-digestive-system 39. hunt je, holst jj, jeppesen pb, kissow h. glp-1 and intestinal diseases. biomedicines. 2021;9(4):383. doi:https://doi.org/10.3390/biomedicines904 0383 https://doi.org/10.1523/jneurosci.1607-04.2004 https://doi.org/10.1523/jneurosci.1607-04.2004 https://doi.org/10.1016/j.jcmgh.2018.04.003 https://doi.org/10.1016/j.jcmgh.2018.04.003 https://my.clevelandclinic.org/health/body/7041-digestive-system https://my.clevelandclinic.org/health/body/7041-digestive-system https://doi.org/10.3390/biomedicines9040383 https://doi.org/10.3390/biomedicines9040383 special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.57 dhr proceedings ǀ http://dhrproceedings.org 67 2022, vol. 2 no. s2 67-71 commentary long term effects post-covid-19 berenice cavazos1,3, amani rangel1,3, melery reynoso1,3, kailee garcia1,2, emily cano1,2, destiny lopez1,3 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2mercedes high school, mercedes, tx 3mercedes early college academy, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/01/2022 accepted for publication 08/05/2022 published 08/05/2022 keywords: covid-19 disease, sars-cov-2, mental health; vaccines introduction covid-19, previously known as “2019 novel coronavirus” is a highly contagious respiratory disease caused by the sars-cov2 virus. covid-19 was first detected in wuhan, china, in late 2019. it then set off a global pandemic. china has infected over 36.5 million individuals and claimed over one million lives worldwide, as of october 8, 2020. [1] covid19 continues to spread rapidly across china and other countries. it has been transmitted to over 200 countries across the globe. this virus is known to spread through person to person contact such as when an infected person coughs, sneezes, or talks. a person may also be exposed to covid-19 by touching surfaces that are contaminated then subsequently touching one’s mouth, eyes, or nose. after getting exposed to the virus, symptoms may appear in 2-14 days. the symptoms include fever or chills, shortness of breath, cough, fatigue, headache, sore throat, congestion or runny nose, muscle or body aches, nausea and vomiting, and diarrhea. when a person experience any of these signs, they are encouraged to seek medical care as soon as possible [2]. after being diagnosed with covid-19, it is recommended to self-isolate for 14 days. this virus became a pandemic due to the fact that people flew out from china to washington d.c after having symptoms of covid-19. in research they have reported that the virus is constantly evolving, spreading through asymptomatic carriers, further making it a high global health threat [3]. with the information found on the cdc website, there are studies still developing on the longterm effects of life post-covid. post-covid effects may manifest symptoms as early as one month and as late as six months after infection [4]. it is estimated that 13.3% get these symptoms at one month or longer, 2.5% at 3 months or longer, if self-reporting, but more than 30% at 6 months among patients who were hospitalized [4]. negative effects covid-19 has and continues to cause many complications such as loss of smell, diabetes signs, respiratory problems, and problems in our circulatory system. and these are just some of the many complications covid-19 has caused. a 2021 study followed 100 people who had mild cases of covid19 and 100 people who repeatedly tested negative. more than a year after their infections, 46% of those who had covid-19 still had smell problems. by https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7212949/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7212949/ https://doi.org/10.3390/v13020202 https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html. cavazos, et al. effects post covid-19 https://doi.org/10.47488/dhrp.v2is2.57 dhr proceedings ǀ http://dhrproceedings.org 68 2022, vol. 2 no. s2 67-71 contrast, just 10% of the control group had developed some smell loss, but for other reasons. furthermore, 7% of those who had been infected still had total smell loss, or ‘anosmia’, at the end of the year. given that more than 500 million cases of covid-19 have been confirmed worldwide, tens of millions of people probably have lingering smell problems [5]. a french research team tracked the sense of smell of 97 patients averaging about 39 years of age. all had lost their sense of smell after contracting covid-19 [6]. in november 2020, a global analysis published in the journal diabetes, obesity and metabolism found that up to 14.4% of people who were hospitalized with severe covid-19 also developed diabetes [7]. covid-19 can cause lung complications such as pneumonia and, in the most severe cases, acute respiratory distress syndrome, or ards. sepsis, another possible complication of covid-19, can also cause lasting harm to the lungs and other organs [8]. acute cardiovascular complications of covid-19 infection include myocarditis, pericarditis, acute coronary syndrome, heart failure, pulmonary hypertension, right ventricular dysfunction, and arrhythmia [9]. covid-19 has also affected our living situations and not just our health. the pandemic has decimated jobs and placed millions of livelihoods at risk. as breadwinners lose jobs, fall ill and die, the food security and nutrition of millions of women and men are under threat, with those in low-income countries, particularly the most marginalized populations, which include small-scale farmers and indigenous peoples, being the hardest hit. the economic and social disruption caused by the pandemic is devastating: tens of millions of people are at risk of falling into extreme poverty, while the number of undernourished people, currently estimated at nearly 690 million, could increase by up to 132 million by the end of the year [10]. mental health reports indicate that covid-19 may have influenced mental health issues with disturbances to include anxiety, depression, stress/trauma related disorders and even substance abuse. children and adolescents are experiencing higher levels of anxiety and depression and reports indicate social isolation, loneliness, lack of physical exercise, and family stress to be contributing factors of these issues. in addition, it is believed that females may be at greater risk of suffering from covid-related mental health issues. it is believed that social distancing, school closures and physical restrictions has negatively impacted the mental health of children. the pandemic may have increased long term consequences in the mental health concerns including social anxiety and depression that many are suffering and will continue to suffer from [11]. covid-19 is not only affecting the mental health of children and adolescents, but also parents and health care providers. parents have the added stress of children being homeschooled and the fear of children being infected with covid-19 which has led to an increase of child maltreatment. public healthcare providers suffer from the same fear and anxiety of covid-19 contact in patients they treat which has led them to isolate themselves, increasing their risk of falling into a mental health crisis. this pandemic also caused an increase in eating disorders. there are three identified pathways in which the pandemic may have caused an increase in eating disorder risks. people began to limit their outdoor activities, an increased exposure to anxietyprovoking media and fears of contagion. increased stress, social isolation all play a role in the increases of eating disorders which could have long term health effects on one's body [12]. covid-19 has had a personal effect on some more than others and for some none at all. however, for many the effect has been detrimental, and they will suffer long term effects, whether they be physical healthcare issues of the organs or mental health issues due to the loss of family, friends or just their own struggle of depression and anxiety. mental healthcare professionals and schools must work together to monitor, identify and assess when a person is falling into crisis and provide the best care possible [13]. positive effects while covid-19 has had detrimental effects on public health, the environment may experience some benefit after the isolation period that covid-19 provoked. there is a dramatic difference within the gas going into our lungs; we have cleaner, fresher air since going into contamination [14]. animals returning to their natural behaviors without the in trepidation of humans, some are tracking how fish and mammals are reacting to the decline in tourism [15]. this is probably the best the environment has looked. https://www.nature.com/articles/d41586-022-01589-z https://www.uhhospitals.org/healthy-at-uh/articles/2021/10/smell-and-taste-loss-after-covid-should-you-be-worried#:~:text=%e2%80%9cthe%20good%20news%20is,base%20surgery%20at%20uh. https://wexnermedical.osu.edu/blog/why-are-people-developing-diabetes-after-having-covid19 https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/what-coronavirus-does-to-the-lungs#:~:text=covid%2d19%20pneumonia&text=the%20pneumonia%20that%20covid%2d19,breath%2c%20cough%20and%20other%20symptoms. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/what-coronavirus-does-to-the-lungs#:~:text=covid%2d19%20pneumonia&text=the%20pneumonia%20that%20covid%2d19,breath%2c%20cough%20and%20other%20symptoms. https://pubmed.ncbi.nlm.nih.gov/35507278/#:~:text=long%2dterm%20follow%2dup%20shows,%2c%20hypertension%2c%20and%20diabetes%20mellitus. https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people's-livelihoods-their-health-and-our-food-systems https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people's-livelihoods-their-health-and-our-food-systems https://pubmed.ncbi.nlm.nih.gov/33810225/ https://pubmed.ncbi.nlm.nih.gov/32476175/ https://pubmed.ncbi.nlm.nih.gov/32476175/ https://pubmed.ncbi.nlm.nih.gov/33172840/ https://cen.acs.org/environment/atmospheric-chemistry/covid-19-lockdowns-had-strange-effects-on-air-pollution-across-the-globe/98/i37#:~:text=when%20viewed%20broadly%20and%20globally,acad https://cen.acs.org/environment/atmospheric-chemistry/covid-19-lockdowns-had-strange-effects-on-air-pollution-across-the-globe/98/i37#:~:text=when%20viewed%20broadly%20and%20globally,acad https://www.science.org/content/article/pandemic-stilled-human-activity-what-did-anthropause-mean-wildlife cavazos, et al. effects post covid-19 https://doi.org/10.47488/dhrp.v2is2.57 dhr proceedings ǀ http://dhrproceedings.org 69 2022, vol. 2 no. s2 67-71 yet not all the positives just affect nature; new vaccines for children under 5 months are going into the clinical trials. technology has also evolved new contactless paying systems through phone apps for online entertainment and long distance learning [16]. social mannerisms and cleanliness are now highly acceptable. we’ve made up new ways of being respectful, like swapping out handshakes for head nods. crime has been going down ever since covid19 ended. public health messages are being taken seriously now as the public now has a new understanding of them. hygiene quality has improved as families educate their children on the spreading of germs and establish safer mannerisms, such as covering their mouths when sneezing, coughing, and yawning [17]. family, friends, and coworkers are more tightly knit. we as humans continue to thrive even after the pandemic. we look after each other more and worry about others we didn’t even think about beforehand. even in the medical community, medical collaboration between healthcare providers was unprecedented and worked together to contain the virus in their communities. that communication continues, even today. conclusion covid-19 has impacted our communities in both positive and negative ways. covid-19 has had a detrimental effect on our health and the economy. post-covid-19 syndrome involves a variety of ongoing symptoms that people experience more than four weeks after getting covid-19 including fatigue, fever, respiratory symptoms, heart symptoms or conditions [18]. covid-19 has also affected our economy in numerous ways such as people losing their jobs, reports on 10 million households being behind on rent, and 20 million households reporting having too little to eat in their home [19]. covid-19 is a healthcare crisis that has led to unprecedented impact on healthcare services. at the heart of the unparalleled crisis, doctors face several challenges in treating patients with covid-19. the psychological burden and overall wellness of healthcare workers have received heightened awareness, with research continuing to show high rates of burnout, psychological stress, and suicide. also noted by researchers was anxiety and stress were significantly increased, leading to negative impacts on both self-efficacy and sleep [20]. there have been, however, some positive outcomes from the pandemic. government imposed isolation and lockdowns have had a positive impact on environmental, air pollution, and hygiene [14]. social mannerisms have also improved since the pandemic has come to the united states. many people are now considerate of what they do in public, and they have taken into account keeping our communities clean [17]. one of the most positive outcomes of this pandemic is that many physicians, doctors, and nurses have come together to collaborate on how to take care of our communities and citizens. we have united as humans to overcome this virus, and we have, for the most part. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. rolling updates on coronavirus disease (covid-19). world health organization. accessed jun29 2022 https://www.who.int/emergencies/diseases/n ovel-coronavirus-2019/events-as-theyhappen 2. gulati a, pomeranz c, qamar z, thomas s, frisch d, george g, summer r, desimone j, sundaram b. a comprehensive review of manifestations of novel coronaviruses in the context of deadly covid-19 global pandemic. am j med sci. 2020 jul;360(1):534. doi: 10.1016/j.amjms.2020.05.006. epub 2020 may 11. pmid: 32620220; pmcid: pmc7212949.https://www.ncbi.nlm.nih.gov /pmc/articles/pmc7212949/ 3. sharma, a., ahmad farouk, i., & lal, s. k. (2021). covid-19: a review on the novel coronavirus disease evolution, transmission, detection, control and prevention. viruses, 13(2), 202. https://doi.org/10.3390/v13020202 4. long covid or post-covid conditions. national center for immunization and https://journals.sagepub.com/doi/full/10.1177/20503121211000912 https://journals.sagepub.com/doi/full/10.1177/20503121211000912 https://www.aarp.org/home-family/friends-family/info-2020/etiquette-coronavirus.html https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351 https://www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19-economys-effects-on-food-housing-and https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8611576/#:~:text=at%20the%20heart%20of%20the,%2c%20psychological%20stress%2c%20and%20suicide. https://cen.acs.org/environment/atmospheric-chemistry/covid-19-lockdowns-had-strange-effects-on-air-pollution-across-the-globe/98/i37#:~:text=when%20viewed%20broadly%20and%20globally,acad https://www.aarp.org/home-family/friends-family/info-2020/etiquette-coronavirus.html https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7212949/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7212949/ https://doi.org/10.3390/v13020202 cavazos, et al. effects post covid-19 https://doi.org/10.47488/dhrp.v2is2.57 dhr proceedings ǀ http://dhrproceedings.org 70 2022, vol. 2 no. s2 67-71 respiratory diseases (ncird), division of viral diseases. center for disease control.https://www.cdc.gov/coronavirus/21 9-ncov/long-term-effects/index.html. date accessed 29 jun2022 5. michael marshall (2022) covid and smell loss: answers begin to emerge. https://www.nature.com › news date accessed 29 june 2022 6. (the study was published online june 24 in jama network open). smell and taste loss after covid: should you be worried? https://www.uhhospitals.org › articles › 2021/10 › smell… date accessed 29 june 2022 7. kathleen wyle ( 2021) why are people developing diabetes after having covid-19? https://wexnermedical.osu.edu › blog › whyare-people… date accessed 29 june 2022 8. panagis galiarsatos, 2022) covid-19 lung damage https://www.hopkinsmedicine.org › health › coronavirus date accessed 29 june 2022 9. tobler dl, pruzansky aj, naderi s, ambrosy ap, slade jj. long-term cardiovascular effects of covid-19: emerging data relevant to the cardiovascular clinician. curr atheroscler rep. 2022 jul;24(7):563-570. doi: 10.1007/s11883-022-01032-8. epub 2022 may 4. pmid: 35507278; pmcid: pmc9065238.https://pubmed.ncbi.nlm.nih.g ov › ... 10. ilo, fao, ifad, and who (2020) impact of covid-19 on people's livelihoods, their health and our food system. https://www.who.int › news › item date accessed 28 june 2022 11. meherali, s., punjani, n., louie-poon, s., abdul rahim, k., das, j. k., salam, r. a., & lassi, z. s. (2021). mental health of children and adolescents amidst covid19 and past pandemics: a rapid systematic review. international journal of environmental research and public health, 18(7), 3432. https://doi.org/10.3390/ijerph18073432ment al health of children and adolescents amidst covid-19 and past pandemics: a rapid systematic review. 12. rodgers, r. f., lombardo, c., cerolini, s., franko, d. l., omori, m., fullertyszkiewicz, m., linardon, j., courtet, p., & guillaume, s. (2020). the impact of the covid-19 pandemic on eating disorder risk and symptoms. the international journal of eating disorders, 53(7), 1166–1170. https://doi.org/10.1002/eat.23318 the impact of the covid-19 pandemic on eating disorder risk and symptoms. 13. hertz, m. f., & barrios, l. c. (2021). adolescent mental health, covid-19, and the value of school-community partnerships. injury prevention: journal of the international society for child and adolescent injury prevention, 27(1), 85–86. https://doi.org/10.1136/injuryprev-2020044050 adolescent mental health, covid19, and the value of school-community partnerships. 14. katherine bourzac,(2020). covid-19 lockdowns had strange effects on air pollution across the globe. https://cen.acs.org/environment/atmospheric -chemistry/covid-19-lockdowns-hadstrange-effects-on-air-pollution-across-theglobe/98/i37#:~:text=when%20viewed%20 broadly%20and%20globally,acad. 30 june, 2022 15. erik stokstad, (2020). the pandemic stilled human activity. what did this ‘andropause’ mean for wildlife. https://www.science.org/content/article/pand emic-stilled-human-activity-what-didanthropause-mean-wildlife 30 june, 2022 16. sarah elizabeth adler, (2020). new etiquette rules may change in covid-19 world. https://www.aarp.org/home-family/friendsfamily/info-2020/etiquette-coronavirus.html 30 june, 2022 17. nishant renu(2021), technological advancement in the era of covid-19. https://journals.sagepub.com/doi/full/10.117 7/20503121211000912 30 june, 2022 18. covid-19: long-term effects. mayo clinic. 30 june, 2022 https://www.mayoclinic.org/diseasesconditions/coronavirus/indepth/coronavirus-long-term-effects/art20490351 19. tracking the covid-19 economy’s effect on food, housing, and employment hardships 30 june, 2022. https://www.cbpp.org/research/poverty-andinequality/tracking-the-covid-19-economyseffects-on-food-housing-and https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html https://www.nature.com/articles/d41586-022-01589-z#:~:text=researchers%20are%20learning%20more%20about,how%20they%20might%20revive%20it.&text=researchers%20are%20finally%20making%20headway,coronavirus%20causes%20loss%20of%20smell. https://www.uhhospitals.org/healthy-at-uh/articles/2021/10/smell-and-taste-loss-after-covid-should-you-be-worried https://www.uhhospitals.org/healthy-at-uh/articles/2021/10/smell-and-taste-loss-after-covid-should-you-be-worried https://www.uhhospitals.org/healthy-at-uh/articles/2021/10/smell-and-taste-loss-after-covid-should-you-be-worried https://www.uhhospitals.org/healthy-at-uh/articles/2021/10/smell-and-taste-loss-after-covid-should-you-be-worried https://wexnermedical.osu.edu/blog/why-are-people-developing-diabetes-after-having-covid19 https://wexnermedical.osu.edu/blog/why-are-people-developing-diabetes-after-having-covid19 https://wexnermedical.osu.edu/blog/why-are-people-developing-diabetes-after-having-covid19 https://wexnermedical.osu.edu/blog/why-are-people-developing-diabetes-after-having-covid19 https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people's-livelihoods-their-health-and-our-food-systems https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people's-livelihoods-their-health-and-our-food-systems https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people's-livelihoods-their-health-and-our-food-systems https://pubmed.ncbi.nlm.nih.gov/33810225/ https://pubmed.ncbi.nlm.nih.gov/33810225/ https://pubmed.ncbi.nlm.nih.gov/33810225/ https://pubmed.ncbi.nlm.nih.gov/33810225/ https://pubmed.ncbi.nlm.nih.gov/32476175/ https://pubmed.ncbi.nlm.nih.gov/32476175/ https://pubmed.ncbi.nlm.nih.gov/32476175/ https://pubmed.ncbi.nlm.nih.gov/33172840/ https://pubmed.ncbi.nlm.nih.gov/33172840/ https://pubmed.ncbi.nlm.nih.gov/33172840/ https://cen.acs.org/environment/atmospheric-chemistry/covid-19-lockdowns-had-strange-effects-on-air-pollution-across-the-globe/98/i37#:~:text=when%20viewed%20broadly%20and%20globally,acad https://cen.acs.org/environment/atmospheric-chemistry/covid-19-lockdowns-had-strange-effects-on-air-pollution-across-the-globe/98/i37#:~:text=when%20viewed%20broadly%20and%20globally,acad https://cen.acs.org/environment/atmospheric-chemistry/covid-19-lockdowns-had-strange-effects-on-air-pollution-across-the-globe/98/i37#:~:text=when%20viewed%20broadly%20and%20globally,acad https://cen.acs.org/environment/atmospheric-chemistry/covid-19-lockdowns-had-strange-effects-on-air-pollution-across-the-globe/98/i37#:~:text=when%20viewed%20broadly%20and%20globally,acad https://cen.acs.org/environment/atmospheric-chemistry/covid-19-lockdowns-had-strange-effects-on-air-pollution-across-the-globe/98/i37#:~:text=when%20viewed%20broadly%20and%20globally,acad https://www.science.org/content/article/pandemic-stilled-human-activity-what-did-anthropause-mean-wildlife https://www.science.org/content/article/pandemic-stilled-human-activity-what-did-anthropause-mean-wildlife https://www.science.org/content/article/pandemic-stilled-human-activity-what-did-anthropause-mean-wildlife https://www.aarp.org/home-family/friends-family/info-2020/etiquette-coronavirus.html https://www.aarp.org/home-family/friends-family/info-2020/etiquette-coronavirus.html https://journals.sagepub.com/doi/full/10.1177/20503121211000912 https://journals.sagepub.com/doi/full/10.1177/20503121211000912 https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351 https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351 https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351 https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351 https://www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19-economys-effects-on-food-housing-and https://www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19-economys-effects-on-food-housing-and https://www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19-economys-effects-on-food-housing-and cavazos, et al. effects post covid-19 https://doi.org/10.47488/dhrp.v2is2.57 dhr proceedings ǀ http://dhrproceedings.org 71 2022, vol. 2 no. s2 67-71 20. impact of covid-19 pandemic on healthcare workers. 30 june, 2022 https://www.ncbi.nlm.nih.gov/pmc/articles/p mc8611576/#:~:text=at%20the%20heart% 20of%20the,%2c%20psychological%20stre ss%2c%20and%20suicide. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8611576/#:~:text=at%20the%20heart%20of%20the,%2c%20psychological%20stress%2c%20and%20suicide. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8611576/#:~:text=at%20the%20heart%20of%20the,%2c%20psychological%20stress%2c%20and%20suicide. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8611576/#:~:text=at%20the%20heart%20of%20the,%2c%20psychological%20stress%2c%20and%20suicide. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8611576/#:~:text=at%20the%20heart%20of%20the,%2c%20psychological%20stress%2c%20and%20suicide. special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.65 dhr proceedings ǀ http://dhrproceedings.org 42 2022, vol. 2 no. s2 42-48 commentary the relationship between obesity and cardiovascular disease diana herrera1,2, kiza dunzz1,2, jocelyn salas1,2, yazmin cantu-villarreal1,2, alondra rodriguez1,2, jacqueline chapa1,3, emely martinez1,3, mia valdez1,3 ¹2nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development ²johnny economedes high school ³hidalgo early college high school all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/21/2022 accepted for publication 08/03/2022 published 08/03/2022 introduction do you feel overweight? are you often finding it hard to lose weight with dieting, workouts, and medications? feeling overly tired or short of breath? well, you may find that you and the majority of people within the united states suffer from the same problems. studies show that over 41.9% of 340 million americans suffer from obesity (1). by definition, obesity is defined as abnormal or excessive fat accumulation that presents a risk to health (2). a common health risk seen within many obesity cases is cardiovascular disease. the most commonly known form of cardiovascular disease is the coronary artery disease (cad). cardiovascular disease affects the flow of blood circulation to the heart causing an overall decrease in blood flow, leaving people at high risks for heart attacks (3). over 39.6 percent of the united states adult population suffers from obesity. however, 7.7 percent of this population is affected by severe forms of obesity that have led to extensive heart problems, such as cardiovascular diseases (4). out of the 41.9% of the american population that suffers from obesity, hispanics have a steady rate of 15.8 percent deaths due to cardiovascular disease diagnosis between male and female patients as of 2020 (5). obesity prevalence there is a higher risk for hispanics to suffer from obesity. every 1 in 2 hispanic people are obese and 1 in 13 suffer from severe obesity. since march of 2020, obesity has risen more than 11.4%, as the increasing severity rises 5%. we are the second largest group in the world that struggles with obesity. about 45.8%, approximately 28 million, of hispanics in the us struggle with obesity (6). puerto ricans and mexican american have the highest prevalence with 36.6% and 34.4% respectively, followed by mexicans 25.5% and cubans with 25.8%. the lowest prevalence group was dominicans with 21.5% (7). obesity causes obesity occurs when a person’s weight is greater in comparison to their height. obesity can be found and diagnosed in both children and adults. it can be caused by food consumption or addiction to food. one challenge in the hispanic community is the absence of healthy food options. 29% of hispanics lack exposure to healthy food and struggle to consume herrera, et al. obesity and cardiovascular disease https://doi.org/10.47488/dhrp.v2is2.65 dhr proceedings ǀ http://dhrproceedings.org 43 2022, vol. 2 no. s2 42-48 it (8). other causes of obesity can be the following: excess weight gain due to medication or illness, insufficient sleep that causes metabolic changes, and obesity. an example of excess weight gain could be cushing’s disease, because of this disease it is more likely for someone to gain weight. results of studies have shown that insufficient sleep can have a negative effect on metabolic rates. although it is rare, future generations can inherit the obesity gene (9). a person diagnosed with a disabling health condition while having obesity can face serious challenges, such as weight loss/gain and changes in hunger, limiting the capability of a person to exercise, discomfort/pain, shortage of energy, and the inability to have assets such as money, transport, and support from people (10). obesity symptoms there are seven main symptoms that determine the diagnosis of obesity, although symptoms may vary by each individual. the most obvious symptom is being above their average body weight. according to centers for disease control and prevention, adults with a body mass index (bmi) of 30 to 39.9 are considered obese. if their bmi is higher than that, then they are considered extremely obese (11). another symptom for obesity is sleep apnea, a condition in which a person experiences an irregularity within their breathing patterns while asleep, causing someone’s breathing to stop inconsistently throughout the night. this condition causes many obese people to have trouble fully sleeping through the night, since they wake up often from breathing discomfort to catch their breath (12). obesity can also cause skin problems, such as dry and scratchy skin or acne. according to myamericanurse.com, obese people have a lot of fat stored, increasing the transdermal water loss, causing their skin to get dry and scratchy. acne, on the other hand, is the result of blocked sebaceous channels that lead to oily skin (13). another symptom is gallstones. people with obesity are more likely to have gallstones because they have a higher level of cholesterol in their bile. gallstones are severely painful, and if left untreated, can lead to life threatening issues (14). furthermore, obesity can cause osteoarthritis in the joints, especially the knees. the more a person weighs, the more stress that is added to the joints which causes them to experience pain. osteoarthritis quickly spreads depending on how much stress is added on the joints, worsening if no treatment is prescribed (15). the 6th symptom for obesity is varicose veins. the bass vein center website explains that the pressure from the extra body fat squeezes the walls of the veins, damaging delicate valves that keep your blood flowing from your extremities to your heart. this would explain how being overweight can damage your veins and lead to serious complications for your physical health (16). lastly is asthma, a common respiratory symptom and condition found within many obese people as a result of excess weight found around their chest. according to everydayhealthcenter.com, fat tissues also produce inflammatory substances that could impair lung function and lead to asthma (17). cardiovascular prevalence cardiovascular disease and obesity play a problematic role within the hispanic community and the world in general. over 39.6 percent out of 330 million of the united states adult population are considered obese. however, 7.7 percent of this population is affected by severe forms of obesity that lead to extensive heart problems such as cardiovascular diseases (4,18). hispanics within central america have a higher prevalence of cardiovascular disease, central american men at 54.9% and puerto rican women at 41.0%. large proportions of people within central america (80% of men, 71% of women) had at least 1 health risk factor of developing cardiovascular disease. at least 18.5 percent of hispanics who have lived in the united states 10 years or longer have reported that congenital heart disease and strokes were less prevalent within (4.2% and 2.0% in men; 2.4% and 1.2% in women, respectively) (19). this shows that even though risks are not as prevalent within the hispanic community in the united states compared to the hispanics of the central american communities. obesity is highly prevalent among hispanics. some studies show that more than 70% of males and females in some hispanic groups are overweight and 40% are obese. the prevalence of cardiovascular disease among hispanics was 70% if they had risk factors including obesity. obesity is higher in hispanic women. one study conducted in hispanics, showed that the rate of heart attacks is much higher than in non-hispanics, and particularly higher in hispanic women (20). cardiovascular causes cardiovascular disease is a leading cause of mortality and morbidity in the hispanic population (21). there are many causes of cardiovascular disease, such as occupational exposures, smoking, diet, and lifestyle (22). the first cause is occupational exposures. hispanic workers, such as factory and field herrera, et al. obesity and cardiovascular disease https://doi.org/10.47488/dhrp.v2is2.65 dhr proceedings ǀ http://dhrproceedings.org 44 2022, vol. 2 no. s2 42-48 workers, report more exposure to organic solvents, metals, and pesticides. it is well known that working with metals and pesticides are risk factors for cardiovascular disease. the second cause is smoking. smoking increases inflammation, thrombosis, and oxidation of low-density lipoprotein cholesterol. clinical data support the hypothesis that cigarette smoke exposure increases oxidative stress as a potential mechanism for initiating cardiovascular disease. the third cause is diet. low intake of healthy nutrients promotes cardiovascular disease. consuming more than the recommended saturated fat, sodium, refined carbohydrates, and red meats can also be a risk of cardiovascular disease. improvements in diets were largely attributable to increased consumption of whole grains, nuts, seeds, and legumes, as well as decreased consumption of sugar-sweetened beverages. the final cause is lifestyle. sedentary behaviors are a main risk factor for cardiovascular disease. sedentary behaviors are behaviors where the person is not active or not being productive. therefore, reducing sedentary time should be targeted in the population while also increasing their physical activity levels. the solutions to lower cardiovascular disease are to stop smoking, maintain a proper diet, improve occupational exposures, and enact a better lifestyle. they will also require providing better health care access to the hispanic population (22). cardiovascular symptoms the symptoms of cardiovascular disease are often associated with an irregularity of the heart. heart attacks, heart failures, or arrhythmias are all classifications of the symptoms an adult may experience (23). typically, arrhythmias are known for causing the heart to beat at different paces, which can lead to improper blood pumping of the heart (24). similarly, heart failure inefficiently pumps blood to organs, whereas, in heart attacks, the heart fails to receive oxygen due to blood flow not reaching certain areas of the heart (25). tiredness, swelling of the limbs, chest pain, palpitations or a fluttery heart, indigestion, heartburn, and pain in the upper and lower half of your shoulders may be early signs of cardiovascular disease (23). because cardiovascular disease is not limited to only one experience, these symptoms may or may not relate to a person’s situation. depending on the specific area that was affected, such as the blood vessels or the heart valves, symptoms may vary from person to person. additionally, one may be more vulnerable to cardiovascular disease symptoms based on other conditions, such as an infection, a diseased heart, an arrhythmia, or a non-serious congenital heart defect (26). foremost, it is important to determine how cardiovascular disease is present in your life as a means of understanding the specific symptoms one may be prone to. for instance, in the hispanic population, women and men are 10% more likely to get cardiovascular disease without risk factors and are 70% more likely to develop cardiovascular disease with a previous underlying condition such as diabetes (27). however, hispanic men are more disposed to cardiovascular disease compared to hispanic women (27). the reason could be that most men are not well adjusted to deal with stressful events which can lead to cardiovascular disease (28). around 30% of both hispanic genders have hypertension primarily because of their diet. eating flour tortillas, for example, is a common flatbread in the hispanic population known for raising people’s blood pressure. since tortillas are usually present in most hispanic meals, it can become a significant issue over time. when someone has high blood pressure, blood flow is limited, decreasing the oxygen that reaches the heart and leading to cardiovascular disease (29). unfortunately, most hispanic populations are known for neglecting their personal healthcare, so there is a greater possibility they will be diagnosed with cardiovascular disease throughout their life. cardiovascular treatment for those that are diagnosed with cardiovascular disease and fear their wellbeing, there is no reason to fret. there are many different lifestyle treatments as well as medications that could help in the prevention and overall treatment of heart disease. to start off, there are two alternative forms of treatment that can be used for cardiovascular disease. the first option of treatments is to switch to a healthier lifestyle to lower cholesterol levels as well as blood pressure that can even lead to obesity. the best way to change up your life is by making decisions to aim for a healthier weight by losing about 3% to 5%, keeping up with physical activities that will regulate those factors, start with a healthy diet with fruits; vegetables and low saturated fats, sodium, sugars and alcohol, and maintain stress so that it can help maintain physical and mental health (30). another route that could potentially be taken as an alternative route to treat your heart disease if making lifestyle changes may appear too hard is medication. medications such as ace inhibitors and beta blockers can help lower blood pressure as well as decrease how hard the heart may be working (30). in addition to this, other medications such metformin or nitrates can help regulate build up in the arteries, as well as a preventative for diabetes herrera, et al. obesity and cardiovascular disease https://doi.org/10.47488/dhrp.v2is2.65 dhr proceedings ǀ http://dhrproceedings.org 45 2022, vol. 2 no. s2 42-48 along the way (30). all in all, there are two solutions that may be taken in order to take a step further in preventing cardiovascular disease from happening, especially if you are more prone to get it, or have already suffered from it. for the most part, making basic changes to the way you live may be considered the best option, while taking medications can also be a key factor for those that may have trouble. however, there are situations where sometimes treatment may not work, and therefore lead to other health problems. tying back to the relationship between obesity and cardiovascular disease, it is seen that being obese may eventually lead you to developing heart disease, due to the fact that it can change cholesterol levels or even causing blood pressure to rise (31). for the majority of the hispanic community, cases of obesity and heart disease are extremely prevalent. due to the fact that such a high percentage of our population is prone to both obesity and cardiovascular disease, it is something we may need to be on the lookout for. one of the greatest problems that leads to this frequency in these numbers is lack of healthcare that is available for the hispanic population. as well as that, it is seen that hispanics are less likely to seek out care for their mental health which could lead to stress and therefore stress eating, gaining weight, or an increase in blood pressure (32). obesity treatment there are many ways to treat and prevent obesity. there is nonpharmacological treatment, treatment without the use of medication, and pharmacotherapy, treatment with the use of medication. nonpharmacological treatment includes physical activity, diets, and behavior therapy (33,34). when losing weight begins, it is recommended to start physical activity. exercise keeps the body active and increases energy expenditure causing negative caloric balance. negative caloric balance occurs when more calories are being burned than taken in (33). walking for 30 to 40 minutes for at least three days out of the week is a good way to start. the patient can gradually increase their exercise regimen with 20 minutes of jogging. as the patient increases their endurance and begins to feel comfortable, they can increase their exercise to include running, swimming, and even cardio. as they increase the number of exercises, they can also increase the number of days and time they work out. diets are also able to aid in the treatment of obesity. low calorie diets and prepackaged foods will help with the calorie intake, as the meal is already made and avoids sugars and calories one may overlook while making their own meal (33,35). calorierestricting diets are not only good for losing weight, but also play a role in cardiovascular health (35). behavior modification treatment targets the patient’s habits explicitly. by using behavior modification treatment, the habits that caused the weight gain are analyzed. the goal of behavior modification is to change the patient’s eating habits and encourage a healthier lifestyle. pharmacotherapy is recommended and used on patients who are unable to lose enough weight with the treatments used in the nonpharmacological approach. there are other requirements that must be met to be able to use these drugs, like high bmi and an obesity-related condition (33). there are both long-term and short-term drugs that are used to treat obesity. some of the short-term drugs that stimulate norepinephrine release are benzphetamine hydrochloride, phendimetrazine tartrate, phentermine hydrochloride or tartrate, and diethylpropion. another short-term drug would be mazindol; this drug targets ne reuptake. long-term medications include sibutramine, which blocks norepinephrine and serotonin reuptake, and orlistat, which blocks gastric and pancreatic lipases (34). these long-term medications can also help to maintain weight loss. the fda approved all the mentioned medications. conclusion evidently, over 39.6 percent of 330 million adults within the united states suffer from obesity and over 7.7 percent of this population suffer from severe forms of obesity that cause many underlying conditions such as cardiovascular disease (4,18). 70% of these obese hispanic groups are more prevalent to developing cardiovascular disease as one of the major underlying conditions of obesity (20). although obesity and cardiovascular disease are great concerns for our health, there are many ways to detect, treat, and control them, such as health and dietary plans, therapy both psychologically and physically therapeutic treatments, and for those that may want to take different routes there are pharmaceutically mediated drug treatments offered as well. luckily, we have great doctors, who specialize in these types of treatment such as cardiologists and bariatricians, that are able to medically support hispanics by promoting healthy lifestyle tips as well as using their scope of practice to treat patients; by doing so, there is hopes to lower the mortality rate that these conditions bring forth to the community. therefore, being informed about the risk factors of obesity and cardiovascular disease in the hispanic community is crucial. it is never too late to ask for help, and even more so to herrera, et al. obesity and cardiovascular disease https://doi.org/10.47488/dhrp.v2is2.65 dhr proceedings ǀ http://dhrproceedings.org 46 2022, vol. 2 no. s2 42-48 educate oneself on these topics that could potentially save a life ahead of time. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. cdc. (2021, february 11). adult obesity facts. centers for disease control and prevention. https://www.cdc.gov/obesity/data/adult.html 2. world health organization. (2022). obesity. world health organization. https://www.who.int/healthtopics/obesity#tab=tab_1 3. cdc. (2019, may 14). heart health information: about heart disease. centers for disease control and prevention. https://www.cdc.gov/heartdisease/about.htm 4. american heart association news. “cardiovascular diseases affect nearly half of american adults, statistics show.” www.heart.org, american heart association, 2019,www.heart.org/en/news/2019/01/31/ca rdiovascular-diseases-affect-nearly-half-famerican-adults-statisticsshow.cardiovascular diseases affect nearly half of american adults, statistics show | american heart association 5. centers for disease control and prevention, national center for health statistics. about multiple cause of death, 1999–2020. cdc wonder online database website. atlanta, ga: centers for disease control and prevention; 2022. accessed february 21, 2022. https://www.cdc.gov/heartdisease/facts.htm 6. cdc. (2021, november 12). obesity is a common, serious, and costly disease. centers for disease control and prevention. https://www.cdc.gov/obesity/data/adult.html #:~:text=obesity%20affects%20some%20gr oups%20more%20than%20others&text=no n%2dhispanic%20black%20adults%20 7. hill, s. e., bell, c., bowie, j. v., kelley, e., furr-holden, d., laveist, t. a., & thorpe, r. j. (2015). differences in obesity among men of diverse racial and ethnic background. american journal of men’s health, 11(4), 984–989. https://doi.org/10.1177/1557988315580348 8. for latinos, access to healthy foods can be sporadic. (2016, june 1). bread for the world. https://www.bread.org/blog/latinosaccess-healthy-foods-can-besporadic#:~:text=in%20a%20national%20su rvey%2c%20more 9. cdc. (2022, march 21). causes and consequences of childhood obesity. centers for disease control and prevention. https://www.cdc.gov/obesity/basics/causes.h tml 10. cdc. (2018, november 19). disability and obesity. centers for disease control and prevention. https://www.cdc.gov/ncbddd/disabilityandhe alth/obesity.html 11. cdc. (2021, june 7). defining adult overweight and obesity. centers for disease control and prevention. https://www.cdc.gov/obesity/basics/adultdefining.html?cdc_aa_refval=https%3a %2f%2fwww.cdc.gov%2fobesity%2fadult %2findex.html 12. jehan, s., zizi, f., pandi-perumal, s. r., wall, s., auguste, e., myers, a. k., jeanlouis, g., & mcfarlane, s. i. (2017). obstructive sleep apnea and obesity: implications for public health. sleep medicine and disorders: international journal, 1(4), 00019. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc5836788/#s1title 13. american nurse today official journal of the american nurses association (ana). (n.d.). american nurse. https://www.myamericannurse.com/obesityskin-issues-and-skinfold-management/ 14. dieting & gallstones | niddk. (n.d.). national institute of diabetes and digestive and kidney diseases. https://www.niddk.nih.gov/healthinformation/digestivediseases/gallstones/dieting#weight https://www.cdc.gov/obesity/data/adult.html https://www.who.int/health-topics/obesity#tab=tab_1 https://www.who.int/health-topics/obesity#tab=tab_1 https://www.cdc.gov/heartdisease/about.htm https://www.heart.org/en/news/2019/01/31/cardiovascular-diseases-affect-nearly-half-of-american-adults-statistics-show#:~:text=according%20to%20the%20update%2c%20the%20prevalence%20of%20obesity,greater%20proportion%20of%20life%20lived%20with%20cardiovascular%20disease. https://www.heart.org/en/news/2019/01/31/cardiovascular-diseases-affect-nearly-half-of-american-adults-statistics-show#:~:text=according%20to%20the%20update%2c%20the%20prevalence%20of%20obesity,greater%20proportion%20of%20life%20lived%20with%20cardiovascular%20disease. https://www.heart.org/en/news/2019/01/31/cardiovascular-diseases-affect-nearly-half-of-american-adults-statistics-show#:~:text=according%20to%20the%20update%2c%20the%20prevalence%20of%20obesity,greater%20proportion%20of%20life%20lived%20with%20cardiovascular%20disease. https://www.heart.org/en/news/2019/01/31/cardiovascular-diseases-affect-nearly-half-of-american-adults-statistics-show#:~:text=according%20to%20the%20update%2c%20the%20prevalence%20of%20obesity,greater%20proportion%20of%20life%20lived%20with%20cardiovascular%20disease. https://www.heart.org/en/news/2019/01/31/cardiovascular-diseases-affect-nearly-half-of-american-adults-statistics-show#:~:text=according%20to%20the%20update%2c%20the%20prevalence%20of%20obesity,greater%20proportion%20of%20life%20lived%20with%20cardiovascular%20disease. https://www.heart.org/en/news/2019/01/31/cardiovascular-diseases-affect-nearly-half-of-american-adults-statistics-show#:~:text=according%20to%20the%20update%2c%20the%20prevalence%20of%20obesity,greater%20proportion%20of%20life%20lived%20with%20cardiovascular%20disease. https://www.cdc.gov/heartdisease/facts.htm https://www.cdc.gov/obesity/data/adult.html#:~:text=obesity%20affects%20some%20groups%20more%20than%20others&text=non%2dhispanic%20black%20adults%20 https://www.cdc.gov/obesity/data/adult.html#:~:text=obesity%20affects%20some%20groups%20more%20than%20others&text=non%2dhispanic%20black%20adults%20 https://www.cdc.gov/obesity/data/adult.html#:~:text=obesity%20affects%20some%20groups%20more%20than%20others&text=non%2dhispanic%20black%20adults%20 https://www.cdc.gov/obesity/data/adult.html#:~:text=obesity%20affects%20some%20groups%20more%20than%20others&text=non%2dhispanic%20black%20adults%20 https://doi.org/10.1177/1557988315580348 https://www.bread.org/blog/latinos-access-healthy-foods-can-be-sporadic#:~:text=in%20a%20national%20survey%2c%20more https://www.bread.org/blog/latinos-access-healthy-foods-can-be-sporadic#:~:text=in%20a%20national%20survey%2c%20more https://www.bread.org/blog/latinos-access-healthy-foods-can-be-sporadic#:~:text=in%20a%20national%20survey%2c%20more https://www.bread.org/blog/latinos-access-healthy-foods-can-be-sporadic#:~:text=in%20a%20national%20survey%2c%20more https://www.cdc.gov/obesity/basics/causes.html https://www.cdc.gov/obesity/basics/causes.html https://www.cdc.gov/obesity/basics/causes.html https://www.cdc.gov/ncbddd/disabilityandhealth/obesity.html https://www.cdc.gov/ncbddd/disabilityandhealth/obesity.html https://www.cdc.gov/obesity/basics/adult-defining.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fobesity%2fadult%2findex.html https://www.cdc.gov/obesity/basics/adult-defining.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fobesity%2fadult%2findex.html https://www.cdc.gov/obesity/basics/adult-defining.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fobesity%2fadult%2findex.html https://www.cdc.gov/obesity/basics/adult-defining.html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fobesity%2fadult%2findex.html https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5836788/#s1titlehttps://www.ncbi.nlm.nih.gov/pmc/articles/pmc5836788/#s1titlehttps://www.myamericannurse.com/obesity-skin-issues-and-skinfold-management/ https://www.myamericannurse.com/obesity-skin-issues-and-skinfold-management/ https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones/dieting#weight https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones/dieting#weight https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones/dieting#weight herrera, et al. obesity and cardiovascular disease https://doi.org/10.47488/dhrp.v2is2.65 dhr proceedings ǀ http://dhrproceedings.org 47 2022, vol. 2 no. s2 42-48 15. (2018). arthritis.org. https://www.arthritis.org/healthwellness/about-arthritis/relatedconditions/other-diseases/how-fat-affectsosteoarthritis 16. varicose veins: a common side effect of obesity | blog | bass vein center bass vein center. (n.d.). www.bassmedicalgroup.com. retrieved july 20, 2022, from https://www.bassmedicalgroup.com/veincenter-blog/varicose-veins-a-common-sideeffect-of-obesity 17. rodriguez, d. (2019, october 16). what we know about the link between obesity and asthma. everydayhealth.com. https://www.everydayhealth.com/asthma/ob esity-connection.aspx 18. bureau, u. c. (2020). 2020 census illuminates racial and ethnic composition of the country. census.gov. https://www.census.gov/library/stories/2021/ 08/improved-race-ethnicity-measuresreveal-united-states-population-much-moremultiracial.html#:~:text=the%20hispanic% 20or%20latino%20population%20grew%2 0from%2050.5%20million%20(16.3 19. daviglus, m. l., talavera, g. a., aviléssanta, m. l., allison, m., cai, j., criqui, m. h., gellman, m., giachello, a. l., gouskova, n., kaplan, r. c., lavange, l., penedo, f., perreira, k., pirzada, a., schneiderman, n., wassertheil-smoller, s., sorlie, p. d., & stamler, j. (2012). prevalence of major cardiovascular risk factors and cardiovascular diseases among hispanic/latino individuals of diverse backgrounds in the united states. jama, 308(17), 1775–1784. https://doi.org/10.1001/jama.2012.14517 20. cardiovascular disease in hispanics/latinos in the united states and on long island | renaissance school of medicine at stony brook university. (n.d.). renaissance.stonybrookmedicine.edu. https://renaissance.stonybrookmedicine.edu/ surgery/blog/cardiovascular-disease-inhispanics-latinos 21. bulka, c. m., daviglus, m. l., persky, v. w., durazo-arvizu, r. a., lash, j. p., elfassy, t., lee, d. j., ramos, a. r., tarraf, w., & argos, m. (2018). association of occupational exposures with cardiovascular disease among us hispanics/latinos. heart, 105(6), 439–448. https://doi.org/10.1136/heartjnl-2018313463 22. virani, s. s., alonso, a., benjamin, e. j., bittencourt, m. s., callaway, c. w., carson, a. p., chamberlain, a. m., chang, a. r., cheng, s., delling, f. n., djousse, l., elkind, m. s. v., ferguson, j. f., fornage, m., khan, s. s., kissela, b. m., knutson, k. l., kwan, t. w., lackland, d. t., & lewis, t. t. (2020). heart disease and stroke statistics—2020 update. circulation, 141(9). https://doi.org/10.1161/cir.00000000000007 57 23. cdc. (2019, may 14). heart health information: about heart disease. centers for disease control and prevention. https://www.cdc.gov/heartdisease/about.htm 24. american heart association. (2016). about arrhythmia. www.heart.org. https://www.heart.org/en/healthtopics/arrhythmia/about-arrhythmia 25. heart attack vs. heart failure: what are the differences? (2021, may 14). healthline. https://www.healthline.com/health/heart/hea rt-attack-vs-heart-failure#heart-attack 26. mayo clinic. (2021, february 9). heart disease symptoms and causes. mayo clinic. https://www.mayoclinic.org/diseasesconditions/heart-disease/symptomscauses/syc-20353118 27. cardiovascular disease in hispanics/latinos in the united states and on long island | renaissance school of medicine at stony brook university. (n.d.). renaissance.stonybrookmedicine.edu. https://renaissance.stonybrookmedicine.edu/ surgery/blog/cardiovascular-disease-inhispanics-latinos 28. weidner g. why do men get more heart disease than women? an international perspective. j am coll health. 2000 may;48(6):291-4. doi: 10.1080/07448480009596270. pmid: 10863872. 29. cdc. (2021, may 18). about high blood pressure (hypertension). centers for disease control and prevention. https://www.cdc.gov/bloodpressure/about.ht m nih. (2022, march 24). coronary heart disease treatment. national heart lung and blood institute. retrieved july 15, 2022, from https://www.nhlbi.nih.gov/health/coronaryhearthttps://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/how-fat-affects-osteoarthritis https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/how-fat-affects-osteoarthritis https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/how-fat-affects-osteoarthritis https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/how-fat-affects-osteoarthritis http://www.bassmedicalgroup.com./ http://www.bassmedicalgroup.com./ http://www.bassmedicalgroup.com./ http://www.bassmedicalgroup.com./ http://www.bassmedicalgroup.com./ https://www.everydayhealth.com/asthma/obesity-connection.aspx https://www.everydayhealth.com/asthma/obesity-connection.aspx https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html#:~:text=the%20hispanic%20or%20latino%20population%20grew%20from%2050.5%20million%20(16.3 https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html#:~:text=the%20hispanic%20or%20latino%20population%20grew%20from%2050.5%20million%20(16.3 https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html#:~:text=the%20hispanic%20or%20latino%20population%20grew%20from%2050.5%20million%20(16.3 https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html#:~:text=the%20hispanic%20or%20latino%20population%20grew%20from%2050.5%20million%20(16.3 https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html#:~:text=the%20hispanic%20or%20latino%20population%20grew%20from%2050.5%20million%20(16.3 https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html#:~:text=the%20hispanic%20or%20latino%20population%20grew%20from%2050.5%20million%20(16.3 https://doi.org/10.1001/jama.2012.14517 https://renaissance.stonybrookmedicine.edu/surgery/blog/cardiovascular-disease-in-hispanics-latinos https://renaissance.stonybrookmedicine.edu/surgery/blog/cardiovascular-disease-in-hispanics-latinos https://renaissance.stonybrookmedicine.edu/surgery/blog/cardiovascular-disease-in-hispanics-latinos https://renaissance.stonybrookmedicine.edu/surgery/blog/cardiovascular-disease-in-hispanics-latinos https://doi.org/10.1136/heartjnl-2018-313463 https://doi.org/10.1136/heartjnl-2018-313463 https://doi.org/10.1161/cir.0000000000000757 https://doi.org/10.1161/cir.0000000000000757 https://www.cdc.gov/heartdisease/about.htm http://www.heart.org./ http://www.heart.org./ https://www.heart.org/en/health-topics/arrhythmia/about-arrhythmia https://www.heart.org/en/health-topics/arrhythmia/about-arrhythmia https://www.healthline.com/health/heart/heart-attack-vs-heart-failure#heart-attack https://www.healthline.com/health/heart/heart-attack-vs-heart-failure#heart-attack https://www.mayoclinic.org/diseases-conditions/heart-disease/symptoms-causes/syc-20353118 https://www.mayoclinic.org/diseases-conditions/heart-disease/symptoms-causes/syc-20353118 https://www.mayoclinic.org/diseases-conditions/heart-disease/symptoms-causes/syc-20353118 https://renaissance.stonybrookmedicine.edu/surgery/blog/cardiovascular-disease-in-hispanics-latinos https://renaissance.stonybrookmedicine.edu/surgery/blog/cardiovascular-disease-in-hispanics-latinos https://renaissance.stonybrookmedicine.edu/surgery/blog/cardiovascular-disease-in-hispanics-latinos https://renaissance.stonybrookmedicine.edu/surgery/blog/cardiovascular-disease-in-hispanics-latinos https://www.cdc.gov/bloodpressure/about.htm https://www.cdc.gov/bloodpressure/about.htm https://www.cdc.gov/bloodpressure/about.htm https://www.nhlbi.nih.gov/health/coronary-heart-%0cdisease/treatment#:~:text=you%20may%20need%20a%20procedure,the%20artery%20from%20narrowing%20again. https://www.nhlbi.nih.gov/health/coronary-heart-%0cdisease/treatment#:~:text=you%20may%20need%20a%20procedure,the%20artery%20from%20narrowing%20again. herrera, et al. obesity and cardiovascular disease https://doi.org/10.47488/dhrp.v2is2.65 dhr proceedings ǀ http://dhrproceedings.org 48 2022, vol. 2 no. s2 42-48 disease/treatment#:~:text=you%20may%20 need%20a%20procedure,the%20artery%20f rom%20narrowing%20again. 31. penn medicine. (2019, march 25). three ways obesity contributes to heart disease. pennmedicine.org. retrieved july 18, 2022, from https://www.pennmedicine.org/updates/blog s/metabolic-and-bariatric-surgeryblog/2019/march/obesity-and-heart-disease 32. martinez, k. g. (2016, july 27). why it's difficult to get help if you are a latino dealing with nerves or stress. anxiety.org. retrieved july 18, 2022, from https://www.anxiety.org/latino-languageculture-barriers-to-anxiety-diagnosis-andtreatment 33. fujioka, k. (2002). management of obesity as a chronic disease: nonpharmacologic, pharmacologic, and surgical options. obesity research, 10(s12), 116s123s. https://doi.org/10.1038/oby.2002.204 34. phelan, s., & wadden, t. a. (2002). combining behavioral and pharmacological treatments for obesity. obesity research, 10(6), 560–574. https://doi.org/10.1038/oby.2002.77 35. bales, c. w., & porter starr, k. n. (2018). obesity interventions for older adults: diet as a determinant of physical function. advances in nutrition, 9(2), 151–159. https://doi.org/10.1093/advances/nmx016 https://www.nhlbi.nih.gov/health/coronary-heart-%0cdisease/treatment#:~:text=you%20may%20need%20a%20procedure,the%20artery%20from%20narrowing%20again. https://www.nhlbi.nih.gov/health/coronary-heart-%0cdisease/treatment#:~:text=you%20may%20need%20a%20procedure,the%20artery%20from%20narrowing%20again. https://www.nhlbi.nih.gov/health/coronary-heart-%0cdisease/treatment#:~:text=you%20may%20need%20a%20procedure,the%20artery%20from%20narrowing%20again. https://www.pennmedicine.org/updates/blogs/metabolic-and-bariatric-surgery-blog/2019/march/obesity-and-heart-disease https://www.pennmedicine.org/updates/blogs/metabolic-and-bariatric-surgery-blog/2019/march/obesity-and-heart-disease https://www.pennmedicine.org/updates/blogs/metabolic-and-bariatric-surgery-blog/2019/march/obesity-and-heart-disease https://www.anxiety.org/latino-language-culture-barriers-to-anxiety-diagnosis-and-treatment https://www.anxiety.org/latino-language-culture-barriers-to-anxiety-diagnosis-and-treatment https://www.anxiety.org/latino-language-culture-barriers-to-anxiety-diagnosis-and-treatment https://www.anxiety.org/latino-language-culture-barriers-to-anxiety-diagnosis-and-treatment https://doi.org/10.1038/oby.2002.204 https://doi.org/10.1038/oby.2002.77 https://doi.org/10.1093/advances/nmx016 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.82 dhr proceedings ǀ http://dhrproceedings.org 15 2023, vol. 2 no. s2 15-18 commentary the progression of lupus and its manifestation in women throughout age sharlie portales1,2, casandra gomez1,2, hermelindo rios1,2, etziel gonzalez1,3, destiny gonzalez1,4, matthew vela1,6, saanvi gottimukkala1,6, mia garcia1,7, ryan hernandez1,7 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 harlingen south high school, tx 3 mcallen memorial high school, tx 4 psja collegiate school of health professions, tx 5 stisd health professions, tx 6 stisd science academy, tx 7 iyford high school, tx received: june 16, 2023 accepted for publication: october 25, 2023 published: november 16, 2023 introduction lupus affects 1.5 million americans annually, with 16,000 new cases being documented each year.1 however, it’s nine times more common in women than in men and it often strikes during childbearing years.2 lupus is an inflammatory disease that occurs when the immune system targets and attacks its own tissues. it is a complex condition that can manifest in a lot of different ways, making diagnostics and treatment difficult. skin, joints, kidneys, heart, lungs, and even the brain are some of the organs that lupus disease can affect. it may result in organ damage, discomfort, and inflammation, which can cause a variety of symptoms and complications. ovarian insufficiency or dysfunction can be a form of organ damage in women as well.3 the centers for disease control estimate that 1.5 million americans have lupus, which is especially common among women of color.4 with lupus affecting women of all ages, but more predominantly those who are older in age and of color, it is wise to look at the progression of the disease and the various symptoms they may experience as they become older in age. pediatric and neonatal lupus erythematosus during the early stages of pregnancy in women, certain autoantibodies that the fetus had exposure to via the placenta (passive mother to fetus), such as anti-la (ssb) and anti-ro (ssa) resulted in neonatal lupus erythematosus (nle).5 only 2% of nle cases are estimated to affect fetuses where the mother had sjogren syndrome and came into contact with these antibodies.6 an infant with nle can be born with low blood cell counts, liver problems and a skin rash. nle can cause 80% to 95% of severe atrioventricular (av) block cases where the fetus is younger than 28 days of life (neonatal period).7 casualties and mortality rate results in 20% to 30% of infants with cardiac nle.7 medication optimization, constant care, and critical monitoring are required to make sure the fetus is growing and is maintaining proper health. children are also 15-20% of all systemic lupus erythematosis (sle) cases in the united states, this includes all ages below 18.8 the percentage of females suffering from pediatric systemic lupus erythematosus (psle) is around 60% or 70%.6 the symptoms of psle tend to have a more severe effect on the children diagnosed with psle because they are more susceptible to having problems with their kidney and nervous system due to the immunosuppressants given to suppress the lupus special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.82 dhr proceedings ǀ http://dhrproceedings.org 16 2023, vol. 2 no. s2 15-18 flares.8 since they start with the medications at an age where they are still growing compared to adults with sle their bodies are stunted and aren't able to grow normally.9 the symptoms of lupus on children compared to adults with lupus are seen to have a more rapid onset of lupus, lymphadenopathy (the swelling of the lymph nodes), hematological abnormalities, and lupus nephritis.10 sle stays within the children's body as they grow older. lupus in women and the elderly according to the cdc, as of 2021, it is estimated that in 200,000 americans diagnosed with sle, 9 out of 10 of these patients are women ages 15 to 44.11 things that may seem regular to the general population pose a challenge to patients with lupus, such as fertility and pregnancy. fertility in sle patients does not appear to be altered by lupus erythematosus itself; however, problems such as fetal mutation and malformations can occur when women are exposed to cyclophosphamide.10 cyclophosphamide is an immunosuppressant drug used to treat patients with sle. compared to healthy women, patients with sle are prone to danger in pregnancy, which puts the mother and baby at high risk. with pregnancy, a patient can expect for their sle symptoms to flare up. examples of these escalated symptoms include hypertension, built up fluid in the joints, and shortness of breath.12 according to uptodate.com, there was a study conducted which included 385 women who were pregnant with sle. these patients included women who were nonhispanic white, and had moderate sle at the beginning of their pregnancy. the results of this study concluded that 81% of these patients who were pregnant with sle had normal healthy pregnancies. this study also found that the results of patients without risk factors was 7.8% for adverse pregnancy rates. those with risk factors had adverse pregnancy outcomes of 58% and mortality of the baby was 22%. the study population was limited, as it did not include women with high sle activity.13 patients with sle are advised to go through an evaluation prior to contraception as well as a risk assessment to determine whether pregnancy would be suitable. as a woman with sle ages and progresses in life, her lupus erythematosus develops proportionally, and vice versa.14 one factor contributing to this is that as you age, you not only have to deal with your symptoms but also the effects of your disease’s prior activity and the harm it has caused. women diagnosed with sle may have earlier menopause, which ties in with bone and cardiovascular health.15 lupus-related symptoms may improve with age, however the severity of the symptoms may also increase. for instance, sle has a heavy effect on the kidneys of a patient. sle can sometimes lead to lupus nephritis which is the inflammation of the kidneys resulting in kidney failure.16 lupus nephritis is most commonly diagnosed in women ages 20-40, usually appearing within 5 years of your first lupus symptoms.17 other effects of aging with lupus include having to take part in multiple treatments for a symptom which was once controllable with one treatment. sle can also advance into late onset sle which represents the disorder beginning at the ages 55-60 years of age.18 treatment, is it preventable? if not, how can one manage this disease? lupus is a common chronic autoimmune disease found mostly in women and with a general understanding of autoimmune diseases; we can infer that there is no possible cure. therefore, lupus within itself is not preventable, but it can be manageable to contain and minimize the effects that come with it. medications such as: hydroxychloroquine (antimalarial), corticosteroids, azathioprine and other immunosuppressants have been proven to reduce pain and inflammation within the kidneys, lungs, and heart.19 typically, doctors normally use antimalarial to treat malaria, but these medications can also be useful for treating lupus.20 it can treat a variety of skin conditions as well as aid in the decrease of pain and swelling of arthritis, one of many common symptoms of lupus. now certain medications may differ from prescriptions given to patients ranging from different age groups. this is because female teenagers commonly have concerns regarding socialization, body image, psychological state, and competitiveness in sports and in school. they are more likely to experiment with alternative treatments and illicit medications than adults.21 before taking any medications, ask your doctor if it can increase light sensitivity. some medications can make your skin more vulnerable to light, so it is recommended by dermatologists that you protect your skin from the sun. this disease can worsen due to the fact that it causes your skin to become sensitive to ultraviolet (uv) light. use a protective sunscreen, if you have a darker skin tone consider using a tinted sunscreen, so that it will not leave a white cast on your skin.22 the goal is to control your symptoms and reduce any inflammation when it takes place. you can do this by suppressing your overactive immune system with immunosuppressants to prevent any flares if they may occur. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.82 dhr proceedings ǀ http://dhrproceedings.org 17 2023, vol. 2 no. s2 15-18 conclusion as of 2023, lupus is still very common affecting over 1.5 million americans annually with studies showing it most commonly affects women disproportionately compared to men with a 9:10 ratio.1 lupus may present multiple symptoms and vary in complications, which can include organ damage, inflammation, and pregnancy difficulties. while there is no current cure for lupus, it can be regulated with medications such as: hydroxychloroquine (antimalarial) and corticosteroids to manage and minimize the effects of symptoms.20 changes in lifestyle can also aid in the regulation of lupus, which in turn has a positive effect on the patient’s lives.23 as of april 27, 2022 the understanding of lupus progresses, it is imperative to prioritize early detection and patient education to promote a higher quality of life for patients.24 increased awareness and research efforts are necessary to address disparities in lupus prevalence and outcomes among different communities. therefore, it is best to control your symptoms and reduce any inflammation if it may occur as age will not worsen the effects of your symptoms as long as you treat them in a timely manner. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. alharbi s. gastrointestinal manifestations in patients with systemic lupus erythematosus. open access rheumatol. 2022;14:243-253. published 2022 oct 17. doi:10.2147/oarrr.s384256 2. weckerle ce, niewold tb. the unexplained female predominance of systemic lupus erythematosus: clues from genetic and cytokine studies. clin rev allergy immunol. 2011;40(1):42-49. doi:10.1007/s12016-0098192-4 3. angley m, spencer jb, lim ss, howards pp. anti-müllerian hormone in africanamerican women with systemic lupus erythematosus. lupus sci med. 2020;7(1):e000439. doi:10.1136/lupus2020-000439 4. clowse me, grotegut c. racial and ethnic disparities in the pregnancies of women with systemic lupus erythematosus. arthritis care res (hoboken). 2016;68(10):1567-1572. doi:10.1002/acr.22847 5. lazaro d. elderly-onset systemic lupus erythematosus: prevalence, clinical course and treatment. drugs aging. 2007;24(9):701715. doi:10.2165/00002512-20072409000001 6. leung, alexander kc. neonatal lupus erythematosus autoimmune diseases. hindawi, 2 september 2012, https://www.hindawi.com/journals/ad/2012/ 301274/. accessed 9 june 2023. 7. diaz-frias j, badri t. neonatal lupus erythematosus. in: statpearls. treasure island (fl): statpearls publishing; june 27, 2022.diaz-frias, josue. neonatal lupus erythematosus article. statpearls, 27 june 2022, 8. lupus in women. centers for disease control and prevention. published june 28, 2022. https://www.cdc.gov/lupus/basics/women.ht m#source1 9. bermas bl, smith na. uptodate. www.uptodate.com. https://www.uptodate.com/contents/pregnan cy-in-women-with-systemic-lupuserythematosus#h1673942599 10. services d of h & h. lupus and pregnancy. www.betterhealth.vic.gov.au. https://www.betterhealth.vic.gov.au/health/c onditionsandtreatments/lupus-andpregnancy 11. mph, j. j. (2020). how lupus affects the aging process. verywell health. https://www.verywellhealth.com/five-factsabout-lupus-and-aging-2249933 12. karvonen-gutierrez ca, leis a. impact of menopause on women with systemic lupus erythematosus. maturitas. 2021 dec;154:2530. doi: 10.1016/j.maturitas.2021.09.004. epub 2021 sep 11. pmid: 34736577. 13. u.s. department of health and human services. (n.d.). lupus and kidney disease (lupus nephritis) niddk. national institute of diabetes and digestive and kidney diseases. https://www.uptodate.com/contents/pregnancy-in-women-with-systemic-lupus-erythematosus#h1673942599 https://www.uptodate.com/contents/pregnancy-in-women-with-systemic-lupus-erythematosus#h1673942599 https://www.uptodate.com/contents/pregnancy-in-women-with-systemic-lupus-erythematosus#h1673942599 https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/lupus-and-pregnancy https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/lupus-and-pregnancy https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/lupus-and-pregnancy special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.82 dhr proceedings ǀ http://dhrproceedings.org 18 2023, vol. 2 no. s2 15-18 https://www.niddk.nih.gov/healthinformation/kidney-disease/lupusnephritis#:~:text=lupus%20is%20an%20aut oimmune%20disease,transplant%20to%20m aintain%20your%20health 14. how lupus affects the renal (kidney) system. lupus foundation of america. published 2018. https://www.lupus.org/resources/howlupus-affects-the-renal-kidney-system 15. kone-paut i, piram m, guillaume s, tran ta. review: lupus in adolescence. lupus. 2007;16(8):606-612. doi:10.1177/0961203307079562 16. lockshin, m. d. (2019, june 14). how does lupus affect people of different ages over time? hss. retrieved june 14, 2023, from https://www.hss.edu/conditions_lupusacross-the-lifespan-children-teenagersadults-seniors.asp 17. ni l, wright rd, marks s, beresford mw, tullus k. kidney outcomes for children with lupus nephritis. pediatr nephrol. 2021 jun;36(6):1377-1385. doi: 1007/s00467-02004686-1. epub 2020 jul 28. pmid: 32725543; pmcid: pmc8084759. 18. m., dr. sruthi. what is the life expectancy of a child with lupus? survival rate. medicinenet, 1 june 2022, https://www.medicinenet.com/what_is_the_l ife_expectancy_of_a_child_with_lupus/artic le.htm. accessed 15 june 2023. 19. lupus and medication better health channel, https://www.betterhealth.vic.gov.au/health/c onditionsandtreatments/lupus-andmedication. accessed 15 june 2023. 20. medications used to treat lupus. lupus foundation of america, 4 august 2021, https://www.lupus.org/resources/medication s-used-to-treat-lupus. accessed 15 june 2023. 21. lockshin, michael d. how does lupus affect people of different ages over time? hss, 14 june 2019, https://www.hss.edu/conditions_lupusacross-the-lifespan-children-teenagersadults-seniors.asp. accessed 15 june 2023. 22. american academy of dermatology association. lupus and your skin: self-care dermatologists recommend. american academy of dermatology, 23 september 2022, https://www.aad.org/public/diseases/az/lupus-self-care. accessed 14 june 2023. 23. sayadi l, faezi st, hasanpour m, alahmadi sj. the relationship of lifestyle with disease activity among patients with systemic lupus erythematosus: a descriptive-correlational study. mediterr j rheumatol. 2021;32(2):124-133. published 2021 jun 30. doi:10.31138/mjr.32.2.124 24. lupus news. sciencedaily, https://www.sciencedaily.com/news/health_ medicine/lupus/. accessed 15 june 2023. special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.64 dhr proceedings ǀ http://dhrproceedings.org 36 2022, vol. 2 no. s2 36-41 commentary health effects of exposure to secondhand smoke in children: pregnancy through preadolescence thomas cruz1,2, lauren silva1,2, robert ortiz1,2, sarah ortega1,2, itzel y. huerta 1,3,violeta guerra1,3, milca martinez1,3, kaythleen rodriguez1,3, dominick garza1,4 ¹2nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development ²rio hondo high school, rio hondo tx ³roma high school, roma tx ⁴robert vela high school, edinburg tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/21/2022 accepted for publication 08/03/2022 published 08/03/2022 exposure to secondhand smoke during pregnancy through preadolescence is the leading cause of deaths worldwide. although not nearly talked about enough, secondhand smoke (shs) has the same death rate if not more compared to lung cancer caused by first degree smoking. in the following information we will dive into the research that looks into the effects of secondhand smoke on children during pregnancy through preadolescence. types of secondhand smoke vapes/e-cigarettes although commonly construed to be less harmful than your typical standard cigarette, ecigarettes lie under the surface packed with humectants, colorants, nicotine, flavoring, and other bacterial/fungal products. in the rise of electrical cigarette use, the market only grows vastly as do the people affected by the toxicities found in the thousands of chemicals put into the nicotine filled cartridges firsthand or second handedly between the ages of 18-24 with 40% having not been regular cigarette smokers (1). e-cigarette and vape use in the teen population and adults between 2011-2014 showed the increase of the development of cancer in the lungs of unborn children who are affected by the usage of adults or family members around them. the typical user inhales a cocktail of the following substances, propylene glycol and glycerol, flavor additives, nicotine, and in minute quantities, water. all of which can cause long term effects due to the direct inhalation of the harsh chemicals and metals that damage your airways and alveoli (2). cigars secondhand smoke from cigars contains the same toxic chemicals that secondhand cigarettes smoke does (3). this type of smoke can cause or contribute to lung cancer and heart diseases (4). it also cruz, et al. secondhand smoke in children https://doi.org/10.47488/dhrp.v2is2.64 dhr proceedings ǀ http://dhrproceedings.org 37 2022, vol. 2 no. s2 36-41 increases the risk and severity of childhood asthma, ear infections, and upper and lower respiratory infections in children (4). when an unborn child is exposed to secondhand smoke it increases the risk of getting an ear infection. when inhaled smoke irritates the eustachian tube which causes swelling and interferes with pressure in the middle ear, leading to pain, fluid, and infection, which are the most common causes of children’s hearing loss (5). cigarettes when a pregnant woman smokes a cigarette or is exposed to secondhand cigarette smoking it plays a major role on postnatal outcome, it may cumulate negatively during lactation. the nicotine in the baby lasts up to 9 to 11 hours compared to the mother that lasts up to 3-4 hours (5). a baby gets less oxygen and food since cigarettes contain nicotine and it tightens up your blood vessels (6). the baby will get less oxygen when carbon monoxide gets into your bloodstream. monoxide carbon exposure during pregnancy can cause severe damage, including intrauterine hypoxia, serious neurological damage, and even fetal death (6). gender an extensive study made by pediatricians has shown that parents who smoke or have been near smoking areas, are far more likely to have females than males (7). the male gender, some studies show, are more disadvantaged due to the higher possibility of low birthweight and mortality. however, a study in germany showed the contrary stating that ets, smoke that comes from the burning of a tobacco product and is exhaled by smokers, affects the birth weight and risk of small-for-gestational-age of females more than males (8). tobacco smoke and other harmful chemicals can keep the baby in the mother’s womb from having enough oxygen which results in preterm delivery, harm, and even miscarriage in pregnant ladies (9). according to an examination done in 2007 to figure out if maternal smoking affects the baby as it grew older, the birthweight of adolescents with exposure to maternal smoking were 0.26 kilograms lower than those who grew up around no smoke chemicals. in addition, tests on gender affecting the nicotine or plasma cotinine intake were not significant (10). ethnicities previous studies have found significant differences between ethnicities in exposure to secondhand smoke. with the most exposed ethnicities being african american non-hispanics with 41.5%, followed by non-hispanic asians with 22.7%, 17.8% of non-hispanic white, and lastly, 16.2% hispanics (11). the african american population is more prone to being exposed to shs, 66.1% of them are children aged 3-11(12). the indigenous people are also exposed to secondhand smoke at a high rate. according to the study of northern plains, american indian people that didn’t smoke had a 28% higher level of cotinine (an alkaloid found in tobacco) than people in the general population. high exposure to secondhand smoke in the american indian population is caused by the fact that state smoke free laws are not automatically enforced over the tribal nations or reservations, and most indigenous areas do not have the resources to put in place smoke free protection and make sure they are enforced (13). cdc studies in 2011-2012 show that 6.2 million, out of 58 million, that were of hispanic background were exposed to secondhand smoke. approximately 29.9% of them were children aged 3-11(14). studies taken on the asian-american community showed that approximately 38.3% of secondhand smoke exposure happened at home (15). this percentage is lower compared to some of the other ethnicities. this is because 53.9% of asian-americans have a home smoking ban (16). studies on white, non-hispanic showed that 6.8 million out of 58 million non-smokers were exposed to secondhand smoke. about 34.3% of the population was children (17). symptoms / effects pregnancy shs exposure effects throughout toddler years. according to cdc.gov, babies whose mothers smoke or are exposed to secondhand smoke while pregnant are at a higher risk to be born preterm (before the due date). one in every five children who are born preemies are born with a lower-than-average birth weight (9). preterm birth is the leading cause in disability, disease, and sudden infant death syndrome (sids), or even in some cases miscarriage. a few other birth defects caused by being born preterm are undeveloped lungs, or a cleft palate. these defects that the unborn child can develop while in the womb can cause numerous issues that include asthma from the undeveloped lungs, high risk of ear infection, oral problems, and even heart problems caused by the cleft palate which is an opening or slit in the roof of the mouth and lip (9). this is only a few of many birth defects and problems that can develop when a child is exposed to secondhand smoking during pregnancy. as cruz, et al. secondhand smoke in children https://doi.org/10.47488/dhrp.v2is2.64 dhr proceedings ǀ http://dhrproceedings.org 38 2022, vol. 2 no. s2 36-41 the child ages during the first twelve months of life (span of infancy) the disabilities the infant may have can become chronic and chance of sids is at its peak. a study in relation to the infants underdeveloped lungs was done with 1062 mothers with infants who took a questionnaire on whether their infant experienced occasional wheezing, recurrent wheezing, or more frequent wheezing (mfw). 409 of the infants had one or more episodes of wheezing during their first 12 months of life. the infants from the study that fell under the category of mfw had been to the emergency room for not being able to breathe. when the child hits toddler age and begins to learn how to walk and talk there can be complications when learning these. as the child becomes more physically active, they are prone to get out of breath easier due to their underdeveloped lungs. the birth defects and disabilities that the child may have been born with can also cause learning disabilities (18, 19). ages 6-12 the exposure of second-hand smoking in children causes various and serious health consequences. the main symptoms of the effects of being exposed to second-hand smoke are frequent and constant asthma attacks and constant fatigue in tasks as simple as walking. children exposed to secondhand smoke tend to have frequent asthma attacks, this smoke triggers asthma attacks in children, even endangering a child’s life. some symptoms can be wheezing and coughing, in some cases it can even produce the improper development of the child’s lungs (20,21). the first asthma attacks can be very severe but can worsen over time and cause new cases of asthma in the child if they are not attended. even brief exposure to second-hand smoke can damage cells in ways that set the cancer process in motion. according to studies carried out by the (cdc), they show that those children exposed to second-hand smoking tend to have more ear infections, have more fluid in ears, and are often subjected to operations called myringotomie. (a miringotomy or tympanostomy is an operation performed to drain the fluid accumulated in the ear and to balance the air pressure on both sides of the eardrum. in this operation, after aspirating the mucus from the ear, a small tube is inserted that allows air to enter and liquid to exit. this procedure is done to prevent delayed speech development in a child caused by hearing loss). children exposed to secondhand smoking affects children more than it seems, in fact studies show that this can affect children even in development. children exposed to secondhand smoking tend to be shorter than those who grow up in an environment free of tobacco-containing toxins. when the first symptoms of the effect of being exposed to second-hand smoking are not treated, throughout the child’s development or even in his adulthood, he could have serious problems. atherosclerosis can be a problem of many. according to studies done by the (nih), atherosclerosis can begin very early in a child’s life and worsen over time. it can lead to more serious problems such as blood clots, heart attacks and kidney problems among others (22). long term effects a study done on people with dementia showed that being exposed to secondhand smoke in adolescents has an increased risk of various forms of dementia and stroke later in life. there was a total of 2,993 participants in the study. out of the 2,993 people, 1,683 (56.2%) were not exposed to secondhand smoke, while 670 (22.4%) were exposed to 0-1 packs (around 20 cigarettes) daily, and 640 (21.4%) were exposed to over 1 pack daily. the participants with the highest amount of exposure to secondhand smoke showed increased risk of stroke, ad dementia (alzheimer’s disease), and all dementia compared to those who experienced no exposure (23). a second study done on korean adolescents exposed to secondhand smoke at an early age showed that different aspects of their mental health were affected. including stress, insufficient sleep, depressive symptoms, and suicidal ideation. secondhand smoke was reported at an alarming rate of 94.4% in their everyday lives including 20.0% at school, 23.0% at home, and 51.4% for public places. the end of the study showed korean adolescents have a higher chance of experiencing poor mental health issues from being exposed to secondhand smoke (24,25). mortality rate secondhand smoke with children is the leading cause of death worldwide. due to secondhand smoke in children through the ages of 0pre-teens there are more than 880,000 deaths each year. (26) children exposed to secondhand smoke are more prone to get infant death syndrome. this disorder is known for happening unexpectedly, usually the children look healthy, but it is something that happens when you aren’t aware. other conditions that can cause death in infants and pre-teens are respiratory infections, asthma, and aural dysfunctions. secondhand smoking can also cause coronary artery disease which affects the heart’s arteries which supply blood to the heart, this causes plaque to build up and over time it covers the arteries which makes blood get in the heart with no problem. coronary artery disease cruz, et al. secondhand smoke in children https://doi.org/10.47488/dhrp.v2is2.64 dhr proceedings ǀ http://dhrproceedings.org 39 2022, vol. 2 no. s2 36-41 has a 20-30% rise in individuals exposed to secondhand smoke that individuals with no exposure. socioeconomic status researchers from the cdc said 32.5% among women with incomes below the poverty line and 18.3% above the poverty line with this information we can hypothesize that pregnant women below the poverty line are at a greater risk for harming their child (28). in a different study published by a journal article by charlotta pisinger she states in her research children who live in lower socioeconomic status are strongly associated with secondhand smoke (29). in another research paper by mohammad hajizadeh, they found that exposure to secondhand smoke was higher in rural areas in every country (30). in a journal entry from the cdc, they state children who live in multi-unit residences like apartments are more likely exposed to secondhand smoke than children living in single unit homes. conclusion from the research provided we have gained more knowledge of the health effects of exposure to secondhand smoke from a woman's pregnancy throughout preadolescence. secondhand smoke exposure may occur in many different places including at home, at a friend’s or relative’s home, in vehicles, restaurants, parks and playgrounds. the percentage of secondhand smoke exposure was similar for females and males and was higher for youth aged 3-11 years compared to youth aged 12-17 years. secondhand smoke exposure was highest among non-hispanic black youth and lowest among white and hispanic youth. secondhand smoke isn’t really talked about yet is something parents should be aware of. they should protect their children from secondhand smoke since it can cause health issues and even long-term diseases throughout their lives. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set! region one esc gearup college now, career connected and region one esc paths references 1. bhatt jm, ramphul m, bush a. an update on controversies in e-cigarettes. paediatr respir rev. 2020 nov; 36:75-86. doi: 10.1016/j.prrv.2020.09.003. epub 2020 sep 26. pmid: 33071065; pmcid: pmc7518964. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc7518964/ 2. palmisani j, di gilio a, palmieri l, abenavoli c, famele m, draisci r, de gennaro g. evaluation of second-hand exposure to electronic cigarette vaping under a real scenario: measurements of ultrafine particle number concentration and size distribution and comparison with traditional tobacco smoke. toxics. 2019 nov 25;7(4):59. doi: 10.3390/toxics7040059. pmid: 31775282; pmcid: pmc6958336. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc6958336/ 3. american cancer society. health risks of secondhand smoke.2020. https://www.cancer.org/healthy/stay-awayfrom-tobacco/health-risks-oftobacco/secondhand-smoke.html 4. grow by webmd. smoking during pregnancy.2020.https://www.webmd.com/ba by/smoking-duringpregnancy#:~:text=babies%20and%20childr en%20exposed%20to,breathing%20problem s%20worse%20for%20babies 5. ent health. secondhand smoke and children https://www.enthealth.org/be_ent_smart/sec ondhand-smoke-and-children/ 6. the women's royal women’s hospital. breastfeeding & cigarette smoke. https://www.thewomens.org.au/healthinformation/breastfeeding/medicines-drugsand-breastfeeding/breastfeeding-andcigarette-smoke 7. mays d, gilman se, rende r, luta g, tercyak kp, niaura rs. parental smoking exposure and adolescent smoking trajectories. pediatrics. 2014 jun;133(6):98391. doi: 10.1542/peds.2013-3003. epub 2014 may 12. pmid: 24819567; pmcid: pmc4035590.https://www.ncbi.nlm.nih.gov /pmc/articles/pmc4035590/ 8. owili po, muga ma, kuo hw. gender difference in the association between https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7518964/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7518964/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6958336/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6958336/ https://www.cancer.org/healthy/stay-away-from-tobacco/health-risks-of-tobacco/secondhand-smoke.html https://www.cancer.org/healthy/stay-away-from-tobacco/health-risks-of-tobacco/secondhand-smoke.html https://www.cancer.org/healthy/stay-away-from-tobacco/health-risks-of-tobacco/secondhand-smoke.html https://www.webmd.com/baby/smoking-during-pregnancy#:~:text=babies%20and%20children%20exposed%20to,breathing%20problems%20worse%20for%20babies https://www.webmd.com/baby/smoking-during-pregnancy#:~:text=babies%20and%20children%20exposed%20to,breathing%20problems%20worse%20for%20babies https://www.webmd.com/baby/smoking-during-pregnancy#:~:text=babies%20and%20children%20exposed%20to,breathing%20problems%20worse%20for%20babies https://www.webmd.com/baby/smoking-during-pregnancy#:~:text=babies%20and%20children%20exposed%20to,breathing%20problems%20worse%20for%20babies https://www.webmd.com/baby/smoking-during-pregnancy#:~:text=babies%20and%20children%20exposed%20to,breathing%20problems%20worse%20for%20babies https://www.enthealth.org/be_ent_smart/secondhand-smoke-and-children/ https://www.enthealth.org/be_ent_smart/secondhand-smoke-and-children/ https://www.thewomens.org.au/health-information/breastfeeding/medicines-drugs-and-breastfeeding/breastfeeding-and-cigarette-smoke https://www.thewomens.org.au/health-information/breastfeeding/medicines-drugs-and-breastfeeding/breastfeeding-and-cigarette-smoke https://www.thewomens.org.au/health-information/breastfeeding/medicines-drugs-and-breastfeeding/breastfeeding-and-cigarette-smoke https://www.thewomens.org.au/health-information/breastfeeding/medicines-drugs-and-breastfeeding/breastfeeding-and-cigarette-smoke https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4035590/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4035590/ cruz, et al. secondhand smoke in children https://doi.org/10.47488/dhrp.v2is2.64 dhr proceedings ǀ http://dhrproceedings.org 40 2022, vol. 2 no. s2 36-41 environmental tobacco smoke and birth weight in africa. int j environ res public health. 2018 jul 4;15(7):1409. doi: 10.3390/ijerph15071409. pmid: 29973544; pmcid: pmc6069484. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc6069484/#:~:text=a%20stratified%20an alysis%2c%20by%20gender,%3d%201.06 %3b%2095%25%20ci%3a 9. centers for disease and control and prevention (cdc). smoking during pregnancy.https://www.cdc.gov/tobacco/bas ic_information/health_effects/pregnancy/ind ex.htm#:~:text=one%20in%20every%20fiv e%20babies,early%20are%20not%20as%20 healthy. retrieved july 15, 2022 10. neuropsychopharmacology at the intersection of brain, behavior, and therapeutics. gender-specific effects of prenatal and adolescent exposure to tobacco smoke on auditory and visual attention. 2007. https://www.google.com/url?sa=t&rct=j&q= &esrc=s&source=web&cd=&ved=2ahuke wihxn2ksox5ahvekgofhvyiadiqfnoe ccgqaq&url=https%3a%2f%2fwww.nat ure.com%2farticles%2f1301398&usg=ao vvaw0zykrqojchdwcc13laz7qf 11. quickstats: trends in secondhand smoke exposure among nonsmoking adults, by race and hispanic origin — national health and nutrition examination survey, united states, 2009–2018. mmwr morb mortal wkly rep 2021; 70:224. doi: http://dx.doi.org/10.15585/mmwr.mm7006a 6 12. african american people need more protection from secondhand smoke exposure. (cdc)june 27,2022. retrieved july 13, 2022. https://www.cdc.gov/tobacco/healthequity/african-american/secondhandsmoke.html 13. american indian and alaska native people need more protection from exposure to secondhand smoke. (cdc) june 27,2022. retrieved july 14, 2022, https://www.cdc.gov/tobacco/healthequity/aian/secondhand-smoke.html 14. hispanic and latino people and commercial tobacco use: health disparities and ways to advance health equity. (cdc) june 27,2022. retrieved july 14, 2022. https://www.cdc.gov/tobacco/healthequity/hispaniclatino/index.htm?cdc_aa_refval=https%3 a%2f%2fwww.cdc.gov%2ftobacco%2fdi sparities%2fhispanics-latinos%2findex.htm 15. chang e, dove m, saw a, tsoh jy, fung lc, tong ek. home smoking bans and urinary nnal levels to measure tobacco smoke exposure in chinese american household pairs. int j environ res public health. 2021 jul 20;18(14):7682. doi: 10.3390/ijerph18147682. pmid: 34300133; pmcid: pmc8305615. https://pubmed.ncbi.nlm.nih.gov/34300133/ 16. tsai j, homa dm, gentzke as, mahoney m, sharapova sr, sosnoff cs, caron kt, wang l, melstrom pc, trivers kf. exposure to secondhand smoke among nonsmokers united states, 1988-2014. mmwr morb mortal wkly rep. 2018 dec 7;67(48):13421346. doi: 10.15585/mmwr.mm6748a3. pmid: 30521502; pmcid: pmc6329485. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc6329485/ 17. debra j. brody, m.p.h, zhaohui lu, m.s, james tsai, m.d. secondhand smoke exposure among nonsmoking youth: united states, 2013-2016. cdc. august 2019. retrieved july 17,2022 https://www.cdc.gov/nchs/products/databrief s/db348.htm#:~:text=the%20percentage%2 0of%20shs%20exposure,and%20hispanic %20(24.9%25)%20youth. 18. teijeiro, a., cuello, m. n., raiden, m. g., vieyra, r. e., solé, d., ellwood, p., & gomez, r. m. (2020, january 1). the relationship between second-hand smoke and wheezing in infants from córdoba, argentina. allergologia et immunopathologia. retrieved july 14, 2022, from https://pubmed.ncbi.nlm.nih.gov/31629551/ 19. jose a. castro-rodriguez, md, phd., erick forno, md mph, carlos e. rodriguezmartinez, md, msc, and juan c. celedón, md, drph faaaai. (2017, nov. 1). risk and protective factors for childhood asthma: what is the evidence? retrieved july 19, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/p mc5107168/ centers for disease and control and prevention (cdc). health effects of secondhand smoke. 2020. https://www.cdc.gov/tobacco/data_statistics/ fact_sheets/secondhand_smoke/health_effec ts/index.htm#:~:text=their%20lungs%20gro https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6069484/#:~:text=a%20stratified%20analysis%2c%20by%20gender,%3d%201.06%3b%2095%25%20ci%3a https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6069484/#:~:text=a%20stratified%20analysis%2c%20by%20gender,%3d%201.06%3b%2095%25%20ci%3a https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6069484/#:~:text=a%20stratified%20analysis%2c%20by%20gender,%3d%201.06%3b%2095%25%20ci%3a https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6069484/#:~:text=a%20stratified%20analysis%2c%20by%20gender,%3d%201.06%3b%2095%25%20ci%3a https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm#:~:text=one%20in%20every%20five%20babies,early%20are%20not%20as%20healthy https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm#:~:text=one%20in%20every%20five%20babies,early%20are%20not%20as%20healthy https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm#:~:text=one%20in%20every%20five%20babies,early%20are%20not%20as%20healthy https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm#:~:text=one%20in%20every%20five%20babies,early%20are%20not%20as%20healthy https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm#:~:text=one%20in%20every%20five%20babies,early%20are%20not%20as%20healthy https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewihxn2ksox5ahvekgofhvyiadiqfnoeccgqaq&url=https%3a%2f%2fwww.nature.com%2farticles%2f1301398&usg=aovvaw0zykrqojchdwcc13laz7qf https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewihxn2ksox5ahvekgofhvyiadiqfnoeccgqaq&url=https%3a%2f%2fwww.nature.com%2farticles%2f1301398&usg=aovvaw0zykrqojchdwcc13laz7qf https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewihxn2ksox5ahvekgofhvyiadiqfnoeccgqaq&url=https%3a%2f%2fwww.nature.com%2farticles%2f1301398&usg=aovvaw0zykrqojchdwcc13laz7qf https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewihxn2ksox5ahvekgofhvyiadiqfnoeccgqaq&url=https%3a%2f%2fwww.nature.com%2farticles%2f1301398&usg=aovvaw0zykrqojchdwcc13laz7qf https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewihxn2ksox5ahvekgofhvyiadiqfnoeccgqaq&url=https%3a%2f%2fwww.nature.com%2farticles%2f1301398&usg=aovvaw0zykrqojchdwcc13laz7qf https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahukewihxn2ksox5ahvekgofhvyiadiqfnoeccgqaq&url=https%3a%2f%2fwww.nature.com%2farticles%2f1301398&usg=aovvaw0zykrqojchdwcc13laz7qf http://dx.doi.org/10.15585/mmwr.mm7006a6 http://dx.doi.org/10.15585/mmwr.mm7006a6 http://dx.doi.org/10.15585/mmwr.mm7006a6 http://dx.doi.org/10.15585/mmwr.mm7006a6 https://www.cdc.gov/tobacco/health-equity/african-american/secondhand-smoke.html https://www.cdc.gov/tobacco/health-equity/african-american/secondhand-smoke.html https://www.cdc.gov/tobacco/health-equity/african-american/secondhand-smoke.html https://www.cdc.gov/tobacco/health-equity/aian/secondhand-smoke.html https://www.cdc.gov/tobacco/health-equity/aian/secondhand-smoke.html https://www.cdc.gov/tobacco/health-equity/hispanic-latino/index.htm?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2ftobacco%2fdisparities%2fhispanics-latinos%2findex.htm https://www.cdc.gov/tobacco/health-equity/hispanic-latino/index.htm?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2ftobacco%2fdisparities%2fhispanics-latinos%2findex.htm https://www.cdc.gov/tobacco/health-equity/hispanic-latino/index.htm?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2ftobacco%2fdisparities%2fhispanics-latinos%2findex.htm https://www.cdc.gov/tobacco/health-equity/hispanic-latino/index.htm?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2ftobacco%2fdisparities%2fhispanics-latinos%2findex.htm https://www.cdc.gov/tobacco/health-equity/hispanic-latino/index.htm?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2ftobacco%2fdisparities%2fhispanics-latinos%2findex.htm https://pubmed.ncbi.nlm.nih.gov/34300133/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6329485/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6329485/ https://www.cdc.gov/nchs/products/databriefs/db348.htm#:~:text=the%20percentage%20of%20shs%20exposure,and%20hispanic%20(24.9%25)%20youth https://www.cdc.gov/nchs/products/databriefs/db348.htm#:~:text=the%20percentage%20of%20shs%20exposure,and%20hispanic%20(24.9%25)%20youth https://www.cdc.gov/nchs/products/databriefs/db348.htm#:~:text=the%20percentage%20of%20shs%20exposure,and%20hispanic%20(24.9%25)%20youth https://www.cdc.gov/nchs/products/databriefs/db348.htm#:~:text=the%20percentage%20of%20shs%20exposure,and%20hispanic%20(24.9%25)%20youth https://pubmed.ncbi.nlm.nih.gov/31629551/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5107168/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5107168/ https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/index.htm#:~:text=their%20lungs%20gro�w%20less%20than,asthma%20attack%20in%20a%20child https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/index.htm#:~:text=their%20lungs%20gro�w%20less%20than,asthma%20attack%20in%20a%20child https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/index.htm#:~:text=their%20lungs%20gro�w%20less%20than,asthma%20attack%20in%20a%20child cruz, et al. secondhand smoke in children https://doi.org/10.47488/dhrp.v2is2.64 dhr proceedings ǀ http://dhrproceedings.org 41 2022, vol. 2 no. s2 36-41 w%20less%20than,asthma%20attack%20in %20a%20child. 21. healthy children. secondhand smoke and your child’s health / long term effects. https://www.healthychildren.org/english/hea lthissues/conditions/tobacco/pages/dangersof-secondhand-smoke.aspx 22. wang d, juonala m, viikari jsa, wu f, hutri-kähönen n, raitakari ot, magnussen cg. exposure to parental smoking in childhood is associated with high creactive protein in adulthood: the cardiovascular risk in young finns study. j atheroscler thromb. 2017 dec 1;24(12):1231-1241. doi: 10.5551/jat.40568. epub 2017 jul 20. pmid: 28724840; pmcid: pmc5742368. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc5742368/ 23. zhou s, wang k. childhood secondhand smoke exposure and risk of dementia, alzheimer's disease and stroke in adulthood: a prospective cohort study. j prev alzheimers dis. 2021;8(3):345-350. doi: 10.14283/jpad.2021.10. pmid: 34101793.https://pubmed.ncbi.nlm.nih.gov/ 34101793/ 24. kim b, kim hr. associations between secondhand smoke and mental health in korean adolescents. asia pac j public health. 2020 nov;32(8):406-413. doi: 10.1177/1010539520957846. epub 2020 sep 15. pmid: 32929992. https://pubmed.ncbi.nlm.nih.gov/?term=asso ciatons+between+secondhand+smoke+and+ mental+health+in+korean+adolecents&filter =simsearch2.ffrft 25. bang i, jeong yj, park yy, moon ny, lee j, jeon th. secondhand smoking is associated with poor mental health in korean adolescents. tohoku j exp med. 2017 aug;242(4):317-326. doi: 10.1620/tjem.242.317. pmid: 28867706. https://pubmed.ncbi.nlm.nih.gov/28867706/ 26. yousuf h, hofstra m, tijssen j, et al. estimated worldwide mortality attributed to secondhand tobacco smoke exposure, 1990-2016. jama netw open. 2020;3(3): e201177. doi:10.1001/jamanetworkopen.2020.1177.ht tps://jamanetwork.com/journals/jamanetwor kopen/fullarticle/2762812 27. bridgette e. garrett, phd1; brandi n. martell, mph1; ralph s. caraballo, phd, mph1; brian a. king, phd, mph (2019, june 13) socioeconomic differences in cigarette smoking among sociodemographic groups. https://www.cdc.gov/pcd/issues/2019/18_05 53.htm#:~:text=smoking%20prevalence%2 0overall%20was%2041.1,or%20above%20t he%20poverty%20level. 28. charlotta pisinger, lene hammer-helmich, anne helms andreasen, torben jørgensen & charlotte glümer (2012, september 17). social disparities in children’s exposure to secondhand smoke at home: a repeated crosssectional survey. https://ehjournal.biomedcentral.com/articles/ 10.1186/1476-069x-11-65 29. mohammad hajizadeh, arijit nandi the socioeconomic gradient of secondhand smoke exposure in children: evidence from 26 low-income and middle-income countries https://tobaccocontrol.bmj.com/content/25/e 2/e146 30. cdc, people with low socioeconomic status need more protection from secondhand smoke exposure. https://www.cdc.gov/tobacco/healthequity/low-ses/secondhand-smoke.html https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/index.htm#:~:text=their%20lungs%20gro�w%20less%20than,asthma%20attack%20in%20a%20child https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/index.htm#:~:text=their%20lungs%20gro�w%20less%20than,asthma%20attack%20in%20a%20child https://www.healthychildren.org/english/healthissues/conditions/tobacco/pages/dangers-of-secondhand-smoke.aspx https://www.healthychildren.org/english/healthissues/conditions/tobacco/pages/dangers-of-secondhand-smoke.aspx https://www.healthychildren.org/english/healthissues/conditions/tobacco/pages/dangers-of-secondhand-smoke.aspx https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5742368/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5742368/ https://pubmed.ncbi.nlm.nih.gov/34101793/ https://pubmed.ncbi.nlm.nih.gov/34101793/ https://pubmed.ncbi.nlm.nih.gov/?term=associatons+between+secondhand+smoke+and+mental+health+in+korean+adolecents&filter=simsearch2.ffrft https://pubmed.ncbi.nlm.nih.gov/?term=associatons+between+secondhand+smoke+and+mental+health+in+korean+adolecents&filter=simsearch2.ffrft https://pubmed.ncbi.nlm.nih.gov/?term=associatons+between+secondhand+smoke+and+mental+health+in+korean+adolecents&filter=simsearch2.ffrft https://pubmed.ncbi.nlm.nih.gov/?term=associatons+between+secondhand+smoke+and+mental+health+in+korean+adolecents&filter=simsearch2.ffrft https://pubmed.ncbi.nlm.nih.gov/28867706/ https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2762812 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2762812 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2762812 https://www.cdc.gov/pcd/issues/2019/18_0553.htm#:~:text=smoking%20prevalence%20overall%20was%2041.1,or%20above%20the%20poverty%20level. https://www.cdc.gov/pcd/issues/2019/18_0553.htm#:~:text=smoking%20prevalence%20overall%20was%2041.1,or%20above%20the%20poverty%20level. https://www.cdc.gov/pcd/issues/2019/18_0553.htm#:~:text=smoking%20prevalence%20overall%20was%2041.1,or%20above%20the%20poverty%20level. https://www.cdc.gov/pcd/issues/2019/18_0553.htm#:~:text=smoking%20prevalence%20overall%20was%2041.1,or%20above%20the%20poverty%20level. https://ehjournal.biomedcentral.com/articles/10.1186/1476-069x-11-65 https://ehjournal.biomedcentral.com/articles/10.1186/1476-069x-11-65 https://tobaccocontrol.bmj.com/content/25/e2/e146 https://tobaccocontrol.bmj.com/content/25/e2/e146 https://www.cdc.gov/tobacco/health-equity/low-ses/secondhand-smoke.html https://www.cdc.gov/tobacco/health-equity/low-ses/secondhand-smoke.html special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.5 dhr proceedings ǀ http://dhrproceedings.org 53 2024, vol. 4 no. s1 pg. 53-58 manuscript impact of benzodiazepine misuse on adolescent brain development in hispanic youth on the texas-mexico border: a literature review marisol acosta1, makayla garcia¹,², jose gonzalez¹,³, aiden hager¹,⁴, aryanna garza¹,⁵, emily delgado¹,⁶, alexandria garza¹,⁷, amber gonzales¹,⁴, donna grimaldo¹,⁸ 1dhr health high school and community outreach 2 jubilee brownsville academies 3 nikki rowe high school 4 rio hondo high school 5 san isidro high school 6 la joya high school 7 mercedes early college academy 8 idea quest high school received: july 12, 2025 accepted for publication: january 6, 2025 introduction this literature review examines the impact of benzodiazepine misuse on adolescent brain development, focusing specifically on hispanic youth residing on the texas-mexico border. this population faces unique challenges related to access to healthcare, cultural factors influencing substance use, and the potential for cross-border drug trafficking, all of which can significantly impact the prevalence and consequences of benzodiazepine misuse. while research on benzodiazepine effects on brain development exists [1], [2], studies specifically addressing this issue within the context of hispanic adolescents on the border are limited. this review will synthesize existing knowledge from broader adolescent populations and highlight the critical need for targeted research in this vulnerable group. benzodiazepines and brain development: a general overview benzodiazepines (bzds) are commonly prescribed anxiolytics and hypnotics that act primarily through modulation of the gabaa receptor [3], [4]. these receptors are crucial for neurodevelopment, influencing neuronal migration, differentiation, and circuit formation [2]. however, the subunit composition and functional properties of gabaa receptors change throughout development [1], making the developing brain particularly vulnerable to the effects special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.5 dhr proceedings ǀ http://dhrproceedings.org 54 2024, vol. 4 no. s1 pg. 53-58 of bzds. prenatal exposure to bzds, for example, has been linked to alterations in neuronal positioning and cortical network excitability in mice [2]. similarly, neonatal exposure can alter sensitivity to proconvulsant challenges [2]. these findings underscore the potential for long-term neurodevelopmental consequences from early exposure, even in the absence of overt symptoms. furthermore, research suggests that the pharmacology and physiology of gabaa receptors may be altered in brains affected by seizures or epilepsy [1], creating further complexities in understanding the effects of bzd misuse. the impact of bzd misuse on adolescent brain development is further compounded by the co-occurrence of other substance use, as seen in studies reporting that nonmedical use of prescription opioids is a risk factor for bzd misuse in adolescents [5]. adolescent substance use and brain development adolescence is a period of significant brain maturation, characterized by substantial changes in both grey and white matter [6]. this ongoing neurodevelopment makes adolescents particularly susceptible to the adverse effects of substance use, including alcohol and marijuana [7], [8]. studies have shown that adolescent substance users exhibit abnormalities in brain structure and function, including alterations in white matter integrity [8], [9] and impaired executive function [10]. specifically, a study by bava et al. [8] demonstrated that adolescents with extensive alcohol and marijuana use histories showed poorer white matter integrity in several brain tracts compared to their peers with minimal substance use. the impact of repeated substance use during this critical neurodevelopmental window remains a topic of ongoing research [8]. the national consortium on alcohol and neurodevelopment in adolescence (ncanda) [11] is a large-scale, multisite study designed to investigate the complex interplay between alcohol use, neurocognitive functioning, and neuromaturation. this longitudinal study offers valuable insights into the long-term effects of adolescent substance use on brain development. however, the findings from ncanda, while valuable, do not specifically address the issue of benzodiazepine misuse in hispanic youth on the texas-mexico border. hispanic youth and substance use: cultural and social factors hispanic youth, particularly those on the texas-mexico border, face a complex interplay of social and cultural factors that influence substance use patterns and their consequences [12], [13], [14], [15]. acculturative stress, resulting from navigating two distinct cultural contexts, has been linked to increased risk of substance use [13], [16], [17]. perceived discrimination and conflicts with parents regarding acculturation can further exacerbate these challenges [13]. conversely, strong family support and a positive hispanic cultural orientation have been identified as protective factors against substance use [13], [14]. however, these findings are not always consistent. for example, one study indicated that u.s.-born hispanics perceive substances as less risky than their immigrant counterparts [18], highlighting the complexity of cultural influences. furthermore, parental substance use problems have been shown to significantly impact preadolescents' cognitive performance [19], suggesting potential special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.5 dhr proceedings ǀ http://dhrproceedings.org 55 2024, vol. 4 no. s1 pg. 53-58 transgenerational effects that could be particularly relevant in a border community with potential high rates of substance use across generations. the texas-mexico border context: unique challenges the texas-mexico border region presents unique challenges related to substance use among adolescents. increased accessibility to drugs due to proximity to drug trafficking routes [14] could contribute to higher rates of misuse. limited access to healthcare and mental health services, coupled with language barriers and cultural stigma associated with seeking help, may further impede early intervention and treatment [20]. this context necessitates culturally appropriate prevention and intervention strategies that address the specific needs and challenges of this population. the existing literature lacks specific data on the prevalence and impact of benzodiazepine misuse on hispanic adolescents in this unique border region. research gaps and future directions there is a significant gap in research concerning the specific impact of benzodiazepine misuse on the brain development of hispanic adolescents on the texas-mexico border. while the existing literature provides insights into the effects of bzds on brain development in general [1], [2] and the cultural and social factors influencing substance use among hispanic youth [12], [13], a focused investigation of this specific population is crucial. future research should address the following: prevalence and patterns of benzodiazepine misuse: studies are needed to determine the prevalence of benzodiazepine misuse among hispanic adolescents on the texas-mexico border, identifying potential risk factors such as access to drugs, socio-economic factors, and cultural influences. neurodevelopmental outcomes: longitudinal studies are needed to assess the long-term impact of benzodiazepine misuse on brain structure and function in this population, examining the relationship between misuse and neurocognitive outcomes such as executive function, memory, and attention. cultural adaptation of interventions: culturally sensitive prevention and intervention programs are needed to address the unique challenges and needs of hispanic adolescents in this border region. these programs should account for language barriers, cultural stigma, and the complex interplay of acculturation and substance use. mechanisms of action: further research is needed to understand the specific mechanisms through which benzodiazepine misuse impacts brain development in this population, investigating potential interactions with other risk factors, such as genetic predisposition, early life adversity, and co-occurring mental health conditions. conclusion special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.5 dhr proceedings ǀ http://dhrproceedings.org 56 2024, vol. 4 no. s1 pg. 53-58 benzodiazepine misuse poses a significant threat to adolescent brain development, and this risk is likely magnified for hispanic youth residing on the texas-mexico border due to a complex interplay of social, cultural, and environmental factors. while the existing literature provides a foundation for understanding the broader impacts of bzds and adolescent substance use, there is a critical need for targeted research to address the unique challenges faced by this vulnerable population. future studies should focus on determining the prevalence of benzodiazepine misuse, identifying associated risk factors, assessing neurodevelopmental outcomes, and developing culturally appropriate interventions. only through such research can effective strategies be developed to mitigate the harmful effects of benzodiazepine misuse on the brain development of hispanic adolescents in this border region. this review highlights the urgent need for such research to inform effective prevention and intervention efforts. acknowledgements: nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. funding: funded by dhr health high school and community outreach; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references: 1. mcgoldrick mk, galanopoulou as. developmental pharmacology of benzodiazepines under normal and pathological conditions. epileptic disorders. 2014;16(ns1):59-68. doi:https://doi.org/10.1684/epd.2014.0690 2. haas m, qu z, kim th, et al. perturbations in cortical development and neuronal network excitability arising from prenatal exposure to benzodiazepines in mice. european journal of neuroscience. 2013;37(10):15841593.doi:https://doi.org/10.1111/ejn.12167 3. armando lares soto, reyes c. benzodiazepine : abuse and therapeutic uses, pharmacology, and health effects. nova biomedical/nova science publishers, inc; 2012. 4. rudolph u, cretani f, benke d, et al. pharmacology: relaxed but not sleepy; receptor subtype-specific actions of benzodiazepines. science signaling. 1999;1999(5):tw4-tw4. doi:https://doi.org/10.1126/stke.1999.5.tw4 5. carrasco‐garrido p, valentín hernández‐barrera, jiménez‐trujillo i, et al. trends in the nonmedical misuse of benzodiazepines and z‐hypnotics among school‐aged adolescents (2016–2021): gender differences and related factors. child and adolescent mental health. 2024;29(4):345-354. doi:https://doi.org/10.1111/camh.12716 6. luciana m, bjork jm, nagel bj, et al. adolescent neurocognitive development and impacts of substance use: overview of the adolescent brain cognitive development https://doi.org/10.1684/epd.2014.0690 https://doi.org/10.1111/ejn.12167 https://doi.org/10.1126/stke.1999.5.tw4 https://doi.org/10.1111/camh.12716 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.5 dhr proceedings ǀ http://dhrproceedings.org 57 2024, vol. 4 no. s1 pg. 53-58 (abcd) baseline neurocognition battery. developmental cognitive neuroscience. 2018;32:67-79. doi:https://doi.org/10.1016/j.dcn.2018.02.006 7. squeglia lm, jacobus j, tapert sf. the influence of substance use on adolescent brain development. clinical eeg and neuroscience. 2009;40(1):31-38. doi:https://doi.org/10.1177/155005940904000110 8. bava s, jacobus j, thayer re, tapert sf. longitudinal changes in white matter integrity among adolescent substance users. alcoholism: clinical and experimental research. 2012;37:e181-e189. doi:https://doi.org/10.1111/j.1530-0277.2012.01920.x 9. zalesky a, solowij n, yucel m, et al. effect of long-term cannabis use on axonal fibre connectivity. brain. 2012;135(7):2245-2255. doi:https://doi.org/10.1093/brain/aws136 10. gruber sa, sagar ka, dahlgren mk, racine m, lukas se. age of onset of marijuana use and executive function. psychology of addictive behaviors. 2012;26(3):496-506. doi:https://doi.org/10.1037/a0026269 11. brown sa, brumback t, tomlinson k, et al. the national consortium on alcohol and neurodevelopment in adolescence (ncanda): a multisite study of adolescent development and substance use. journal of studies on alcohol and drugs. 2015;76(6):895-908. doi:https://doi.org/10.15288/jsad.2015.76.895 12. strait sc. drug use among hispanic youth: examining common and unique contributing factors. hispanic journal of behavioral sciences. 1999;21(1):89-103. doi:https://doi.org/10.1177/0739986399211007 13. unger jb. cultural influences on substance use among hispanic adolescents and young adults: findings from project red. child development perspectives. 2014;8(1):48-53. doi:https://doi.org/10.1111/cdep.12060 14. gauthier b, bertrand k, nolin p. famille et traitement de la toxicomanie chez les adolescents : étude de cas. hors-thème. 2011;(13):129-150. doi:https://doi.org/10.7202/045424ar 15. unger jb. preventing substance use and misuse among racial and ethnic minority adolescents: why are we not addressing discrimination in prevention programs? substance use & misuse. 2015;50(8-9):952-955. doi:https://doi.org/10.3109/10826084.2015.1010903 16. forster m, dyal sr, baezconde-garbanati l, chou cp, soto dw, unger jb. bullying victimization as a mediator of associations between cultural/familial variables, substance use, and depressive symptoms among hispanic youth. ethnicity & health. 2013;18(4):415-432. doi:https://doi.org/10.1080/13557858.2012.754407 17. forster m, grigsby t, soto dw, schwartz sj, unger jb. the role of bicultural stress and perceived context of reception in the expression of aggression and rule breaking behaviors among recent-immigrant hispanic youth. journal of interpersonal violence. 2014;30(11):1807-1827. doi:https://doi.org/10.1177/0886260514549052 18. warner td, krebs cp, fishbein dh. perceiving the risk of substance use: the roles of nativity, acculturation, and family support among hispanic children. journal of drug issues. 2008;38(1):119-147. doi:https://doi.org/10.1177/002204260803800106 19. navarro g, stinson a, shankula c, lisdahl k. a 55 exploring the impact of parental substance use problems and behavior on pre-adolescent cognitive performance. archives of clinical neuropsychology. published online september 12, 2024. doi:https://doi.org/10.1093/arclin/acae067.069 https://doi.org/10.1016/j.dcn.2018.02.006 https://doi.org/10.1177/155005940904000110 https://doi.org/10.1111/j.1530-0277.2012.01920.x https://doi.org/10.1093/brain/aws136 https://doi.org/10.1037/a0026269 https://doi.org/10.15288/jsad.2015.76.895 https://doi.org/10.1177/0739986399211007 https://doi.org/10.1111/cdep.12060 https://doi.org/10.7202/045424ar https://doi.org/10.3109/10826084.2015.1010903 https://doi.org/10.1080/13557858.2012.754407 https://doi.org/10.1177/0886260514549052 https://doi.org/10.1177/002204260803800106 https://doi.org/10.1093/arclin/acae067.069 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.5 dhr proceedings ǀ http://dhrproceedings.org 58 2024, vol. 4 no. s1 pg. 53-58 20. lu w, todhunter-reid a, mitsdarffer ml, muñoz-laboy m, yoon as, xu l. barriers and facilitators for mental health service use among racial/ethnic minority adolescents: a systematic review of literature. frontiers in public health. 2021;9. doi:https://doi.org/10.3389/fpubh.2021.641605 https://doi.org/10.3389/fpubh.2021.641605 special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.72 dhr proceedings ǀ http://dhrproceedings.org 116 2022, vol. 2 no. s2 116-121 commentary parkinson’s disease rodrigo garcia1,2, sulibella alcantara1,2, amanda tinoco1,2, sheryl thomas1,2, brayan moreno1,3, omar resendez1,3, omar barrera1,3, arely villanueva, oliver solorzano1,2 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2vela high school, edinburg, tx 3zapata high school, zapata, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 08/04/2022 accepted for publication 08/15/2022 published 08/15/2022 introduction parkinson's disease (pd) is a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination (1). symptoms usually begin gradually and worsen over time. as the disease progresses, people may have difficulty walking and talking. parkinson's disease affects 1-2 per 1000 of the population at any time. pd prevalence is increasing with age and pd affects 1% of the population above 60 years (2). the risk of developing pd is twice as high in men than women, but women have a higher mortality rate and faster progression of the disease (3). a race that is most affected is the caucasian population. the prevalence rate of parkinson’s disease has grown more than 50% in the span of five years. sex is an important fact in pd, as a matter of fact it is more common in men than woman by a 2:1 ratio (4). one clear risk is age, parkinson’s develops after 60 and there is a 1% chance of getting parkinson’s disease, but at 80 the chances increase by 5%. the largest study of parkinson’s disease shows hispanics (16%), followed by non-hispanic whites (13.6%), which are the biggest ethnicities that are affected by parkinson’s disease, and the least likely to get parkinson’s disease are african americans (5). parkinson's disease keeps growing, and at the rate that it’s going it is soon to become the worst brain disease. prevalence parkinson’s disease (pd) is the second most common, age-related neurodegenerative disorder, affecting about 3% of the population by the age of 65 and up to 5% of the people over 85 years (6). parkinson's disease is most common in the midwest and the northeast and is twice as likely to affect whites. studies have shown the prevalence in the white population compared to blacks and asians (6). pathophysiology the study of pathophysiology defines parkinson’s disease as the loss of dopaminergic neurons which are the main source of dopamine, a type of neurotransmitter and hormone located in the mammalian central nervous system in the substantia nigra which helps the brain move the body (7). in other words, it tells the brain to create movement of the garcia, et al parkinson’s disease https://doi.org/10.47488/dhrp.v2is2.72 dhr proceedings ǀ http://dhrproceedings.org 117 2022, vol. 2 no. s2 116-121 body. the loss of dopaminergic neurons creates a lewy body which is an abnormal clumping of alpha synuclein, a protein, which when found, indicates the onset of pd (8). clinical presentation motor symptoms according to the clinical symptoms of parkinson’s disease, up to 80% dopaminergic cells in the nigro-striatal system are lost before the symptoms of parkinson’s disease start to appear (9). when fewer dopaminergic neurons in the striatum, it causes impairment of motor control in people with pd (10). initial symptoms of this disease include muscular rigidity (muscle stiffness), resting tremor or loss of balance (11). symptoms of disease progression include sharp muscle pain, loss of mobility, and loss of normal daily activities such as simply being able to walk (12). sex-related differences in motor symptom pattern also play a big role in diagnosis. symptoms in females develop longer after diagnosis than in males (13).in males, usually the first symptoms that show up are signs of freezing gait. freezing gait is one of the most weakening motor symptoms in a patient with parkinson’s disease. it is characterized by a patient's experience of short and temporary episodes of an inability to move their feet forward despite the intentions to walk (14). this leads to frequent falls and loss of independence. although there are differences in the appearance of symptoms, ultimately, pd can be debilitating for both men and women. non-motor symptoms parkinson's disease is a progressive neurological disorder characterized by a large number of motor and non-motor features that can impact on function to a variable degree (15). it is said that non motor features play an excessively important and sometimes dominant role in the management and even the diagnosis of the disorder (16). non-motor symptoms of pd include drooling, loss of smell, and disturbances in sleeping patterns with restless leg syndrome (16). non motor symptoms occasionally appear years ahead of the motor symptoms (17). alongside these symptoms, mental health is also disrupted with bouts of depression, increased risk of dementia, and occurrences of autonomic disturbance (18). patient reflection essays have reported “i feel trapped inside my body . . . as if i’m not in control . . . almost as if someone or something else is running my life.’’ pd makes patients feel they have lost their sense of control of their own mind which then leads to mental health problems (18). although pd is known for its motor symptoms, the non-motor symptoms can be just as debilitating. treatment/diagnosis/risk factors according to the research of john hopkins medicine, it shows that parkinson’s is not a curable disease. treatment for parkinson’s does help with the risk of progression of the disease, doctors typically prescribe medication, or supportive therapies such as occupational therapy, speech therapy, physiotherapy, and even surgery (19). the success rate for physical therapy is four weeks of gait training and eight weeks for balance training, which needs to be continued for the maximum positive results (20). drug development since 1999 had a success rate of 14.9% with the overall 357 trials. the drugs that are used for the patients are levodopa, safinamide, and droxidopa (21). for selfcare, usually patients that are affected with parkinson’s take care of themselves by diet and exercise, like aerobic training, strength training workouts, and balance training workouts. in some cases, people resort to traditional chinese medicine and acupuncture, which aids the patient by relieving symptoms of the disease (22, 23). patients that are diagnosed by a neurologist (diagnosed by the given medical history and signs/symptoms) (24), are given medication, but the medications come with complications. carbidopalevodopa (sinemet) can induce nausea, hallucinations, confusion, lightheadedness, and dyskinesia. on the other hand, dopamine agonists (pramipexole, ropinirole, rotigotine patch) can induce nausea, dizziness, leg swelling, sleepiness, sleep attacks, worsening cognition, hallucinations, and impulse control disorders (25). with the side effects and the rising cost, depending on whether the person's insurance may be covered or they might not have insurance in general, some patients would resort to not taking any treatments. if the patient does not take any form of treatment, pd will progress at a much faster rate, and more complications will occur throughout the patient's life such as apathy, depression, anxiety, psychosis, sleep disorders, and cognitive impairment (26). therapies medical therapies should address both motor and non-motor symptoms. there are several therapies that can help patients recuperate involving exercise that encourages maintaining muscle strength, increasing flexibility and motion, improving cardiovascular function, walking, jogging, running, https://www.ncbi.nlm.nih.gov/books/n/nicecg35/glossary/def-item/glossary.gl1-d65/ garcia, et al parkinson’s disease https://doi.org/10.47488/dhrp.v2is2.72 dhr proceedings ǀ http://dhrproceedings.org 118 2022, vol. 2 no. s2 116-121 swimming, cycling. while not curative, these exercises reduce the risk of progression of the disease. other non-pharmacological therapies for parkinson’s include education, support groups, speech therapy and nutrition therapy (27). there was a hypothesis about empirical evidence, turns out their hypothesis was indeed incorrect. although there are some factors, there's no remedy that can help the disease from advancing from the host. in addition to non-medicinal therapies, drugs such as levodopa, can be very effective against the disease. if a patient consumes (carbidopa/levodopa) with 10/100mg and is weight 2263. the side effect will be low blood pressure, nausea, confusion, dynsekia. the drug's main focus is converting dopamine into the cerebrum (28). although there are many therapies to combat or stabilize parkinson's disease that are not possible to prevent, some habits can reduce it. surgical therapies there is only one approved surgical therapy of the different brain structures that has been studied and used for parkinson's disease for several decades. people who are living with parkinson's disease may be a candidate for deep brain stimulation (29). deep brain stimulation has become an official therapeutic tool for treating patients with parkinson's disease. it is an elective surgical procedure in which electrodes are implanted into certain areas of the brain. although, one of the main dilemmas of deep brain stimulation are side effects such as tiredness, depression, and suicide (30). this treatment is clear for people who have had parkinson's disease for at least four years. some benefits of deep brain stimulation are to get up to five additional good movements without dyskinesia. it also benefits you to use less medication, and just improves a better quality of life. experimental therapies while traditional therapies may help some patients, there is no known cure for pd. parkinson's disease is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves. current treatment focuses on the symptoms of the disease and mainly involves replacement of dopamine deficiency. (31) dopamine deficiency is having low levels of dopamine, a neurotransmitter and hormone that regulates blood pressure, motivation, helps with memory and learning, increasing attention and focus. (31). patients with parkinson's disease benefit from dopamine replacement therapy by seeing improved outcomes for conditions linked to interference and decreased results for disorders linked to facilitation. while treatment for parkinson’s is very scarce one of the current experimental treatments is medical marijuana. medical marijuana is being used at the moment as an experimental therapy to relax the minds (32). medical marijuana is currently being used by 44% of the population with pd (32). cbd (cannabidiol) and thc (tetrahydrocannabinol) are responsible for the medicinal effects of marijuana. medical marijuana helps with regulating memory, pleasure, concentration, thinking, movement, concentration, sensory and time perception, pain, and much more. cbd (cannabidiol) inhibits the psychotropic effects of thc (tetrahydrocannabinol) and improves its tolerability and therapeutic window, without being intoxicated. (32) medical marijuana helps both motor and non-motor symptoms including bradykinesia, rigidity, tremor, sleep, and pain. medical marijuana has greatly improved pd patients. conclusion parkinson’s disease has reached many people throughout our society. it has affected both men and women. parkinson’s disease is the second most neurodegenerative disease; it has affected more than 6 million people in the world (33). knowledge of the disease manifestations, the treatments, and the progressive long-term course of the disease is necessary to maintain a normal life. no cure has yet been found for such illness, however, clinical trials continue with research for a better quality of life. clinical trials have advanced for parkinson’s disease to gain access for new research treatments to find cure for disease. clinical trials are performed by nonprofit organizations, such as the michael j. fox foundation (33). it focuses on studies that increase the chances of slowing the progression of pd. patients participating in clinical research are important in an effort to provide research and outcomes in which studies were expanded to include anti-inflammatory agents to reduce inflammatory processes in the brain (33). there are ongoing studies in every clinical phase. studies are focusing on targeting dopaminergic symptom relief, and evaluating supplements and other remedies such as cannabidiol, melatonin, and probiotics (33). the hope and goal of research is that some day in the near future a cure is found to treat pd to improve the quality of life of patients afflicted with pd. in addition, a cure would make pd a disease of the past, so that patients with pd can enjoy a life of dignity/happiness with loved ones. garcia, et al parkinson’s disease https://doi.org/10.47488/dhrp.v2is2.72 dhr proceedings ǀ http://dhrproceedings.org 119 2022, vol. 2 no. s2 116-121 acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected and region one esc paths references 1. u.s. department of health and human services. (n.d.). parkinson's disease: causes, symptoms, and treatments. national institute on aging. retrieved august 3, 2022, from https://www.nia.nih.gov/health/parkinsonsdisease#:~:text=parkinson's%20disease%20i s%20a%20brain,have%20difficulty%20wal king%20and%20talking. 2. cacabelos r. parkinson's disease: from pathogenesis to pharmacogenomics. int j mol sci. 2017 mar 4;18(3):551. doi: 10.3390/ijms18030551. pmid: 28273839; pmcid: pmc5372567. 3. tysnes ob, storstein a. epidemiology of parkinson's disease. j neural transm (vienna). 2017 aug;124(8):901-905. doi: 10.1007/s00702-017-1686-y. epub 2017 feb 1. pmid: 28150045. 4. cerri s, mus l, blandini f. parkinson's disease in women and men: what's the difference? j parkinsons dis. 2019;9(3):501515. doi: 10.3233/jpd-191683. pmid: 31282427; pmcid: pmc6700650. 5. gbd 2016 parkinson's disease collaborators. global, regional, and national burden of parkinson's disease, 1990-2016: a systematic analysis for the global burden of disease study 2016. lancet neurol. 2018 nov;17(11):939-953. doi: 10.1016/s14744422(18)30295-3. epub 2018 oct 1. erratum in: lancet neurol. 2021 dec;20(12):e7. pmid: 30287051; pmcid: pmc6191528. 6. ben-joseph a, marshall cr, lees aj, noyce aj. ethnic variation in the manifestation of parkinson's disease: a narrative review. j parkinsons dis. 2020;10(1):31-45. doi: 10.3233/jpd-191763. pmid: 31868680; pmcid: pmc7029316. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc7029316/#:~:text=most%20studies%20r eport%20the%20highest,of%20pd%20risk %20than%20ethnicity. 7. purdy, m. c. (2021, february 9). parkinson's u.s. rates highest in whites, hispanics, and midwest, northeast the source washington university in st. louis. the source. retrieved august 3, 2022, from https://source.wustl.edu/2010/01/parkinsonus-rates-highest-in-whites-hispanics-andmidwest-northeast/ 8. van den eeden sk, tanner cm, bernstein al, fross rd, leimpeter a, bloch da, nelson lm. incidence of parkinson's disease: variation by age, gender, and race/ethnicity. am j epidemiol. 2003 jun 1;157(11):101522. doi: 10.1093/aje/kwg068. pmid: 12777365. https://pubmed.ncbi.nlm.nih.gov/?term=par kinson%27s+and+hispanics 9. sveinbjornsdottir s. the clinical symptoms of parkinson's disease. j neurochem. 2016 oct;139 suppl 1:318-324. doi: 10.1111/jnc.13691. epub 2016 jul 11. pmid: 27401947. 10. cacabelos r. parkinson's disease: from pathogenesis to pharmacogenomics. int j mol sci. 2017 mar 4;18(3):551. doi: 10.3390/ijms18030551. pmid: 28273839; pmcid: pmc5372567. 11. cerri s, mus l, blandini f. parkinson's disease in women and men: what's the difference? j parkinsons dis. 2019;9(3):501515. doi: 10.3233/jpd-191683. pmid: 31282427; pmcid: pmc6700650. 12. beitz jm. parkinson's disease: a review. front biosci (schol ed). 2014 jan 1;6(1):6574. doi: 10.2741/s415. pmid: 24389262. 13. cerri s, mus l, blandini f. parkinson's disease in women and men: what's the difference? j parkinsons dis. 2019;9(3):501515. doi: 10.3233/jpd-191683. pmid: 31282427; pmcid: pmc6700650. 14. cacabelos r. parkinson's disease: from pathogenesis to pharmacogenomics. int j mol sci. 2017 mar 4;18(3):551. doi: 10.3390/ijms18030551. pmid: 28273839; pmcid: pmc5372567. rodrigo 15. jankovic j. parkinson's disease: clinical features and diagnosis. j neurol neurosurg psychiatry. 2008 apr;79(4):368-76. doi: 10.1136/jnnp.2007.131045. pmid: 18344392. 16. pfeiffer rf. non-motor symptoms in parkinson's disease. parkinsonism relat https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://www.nia.nih.gov/health/parkinsons-disease#:~:text=parkinson's%20disease%20is%20a%20brain,have%20difficulty%20walking%20and%20talking. https://pubmed.ncbi.nlm.nih.gov/28273839/ https://pubmed.ncbi.nlm.nih.gov/28273839/ https://pubmed.ncbi.nlm.nih.gov/28273839/ https://pubmed.ncbi.nlm.nih.gov/28273839/ https://pubmed.ncbi.nlm.nih.gov/28273839/ https://pubmed.ncbi.nlm.nih.gov/28150045/ https://pubmed.ncbi.nlm.nih.gov/28150045/ https://pubmed.ncbi.nlm.nih.gov/28150045/ https://pubmed.ncbi.nlm.nih.gov/28150045/ https://pubmed.ncbi.nlm.nih.gov/28150045/ https://pubmed.ncbi.nlm.nih.gov/31282427/ https://pubmed.ncbi.nlm.nih.gov/31282427/ https://pubmed.ncbi.nlm.nih.gov/31282427/ https://pubmed.ncbi.nlm.nih.gov/31282427/ https://pubmed.ncbi.nlm.nih.gov/31282427/ https://pubmed.ncbi.nlm.nih.gov/30287051/ https://pubmed.ncbi.nlm.nih.gov/30287051/ https://pubmed.ncbi.nlm.nih.gov/30287051/ https://pubmed.ncbi.nlm.nih.gov/30287051/ https://pubmed.ncbi.nlm.nih.gov/30287051/ https://pubmed.ncbi.nlm.nih.gov/30287051/ https://pubmed.ncbi.nlm.nih.gov/30287051/ https://pubmed.ncbi.nlm.nih.gov/30287051/ https://pubmed.ncbi.nlm.nih.gov/30287051/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7029316/#:~:text=most%20studies%20report%20the%20highest,of%20pd%20risk%20than%20ethnicity. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7029316/#:~:text=most%20studies%20report%20the%20highest,of%20pd%20risk%20than%20ethnicity. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7029316/#:~:text=most%20studies%20report%20the%20highest,of%20pd%20risk%20than%20ethnicity. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7029316/#:~:text=most%20studies%20report%20the%20highest,of%20pd%20risk%20than%20ethnicity. https://source.wustl.edu/2010/01/parkinson-us-rates-highest-in-whites-hispanics-and-midwest-northeast/ https://source.wustl.edu/2010/01/parkinson-us-rates-highest-in-whites-hispanics-and-midwest-northeast/ https://source.wustl.edu/2010/01/parkinson-us-rates-highest-in-whites-hispanics-and-midwest-northeast/ https://pubmed.ncbi.nlm.nih.gov/?term=parkinson%27s+and+hispanics https://pubmed.ncbi.nlm.nih.gov/?term=parkinson%27s+and+hispanics https://onlinelibrary.wiley.com/doi/abs/10.1111/jnc.13691 https://onlinelibrary.wiley.com/doi/abs/10.1111/jnc.13691 https://onlinelibrary.wiley.com/doi/abs/10.1111/jnc.13691 https://onlinelibrary.wiley.com/doi/abs/10.1111/jnc.13691 https://onlinelibrary.wiley.com/doi/abs/10.1111/jnc.13691 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5372567/from%20pathogenesis%20to%20pharmacogenomics.%20int%20j%20mol%20sci.%202017%20mar%204;18(3):551.%20doi:%2010.3390/ijms18030551.%20pmid:%2028273839;%20pmcid:%20pmc5372567. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5372567/from%20pathogenesis%20to%20pharmacogenomics.%20int%20j%20mol%20sci.%202017%20mar%204;18(3):551.%20doi:%2010.3390/ijms18030551.%20pmid:%2028273839;%20pmcid:%20pmc5372567. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5372567/from%20pathogenesis%20to%20pharmacogenomics.%20int%20j%20mol%20sci.%202017%20mar%204;18(3):551.%20doi:%2010.3390/ijms18030551.%20pmid:%2028273839;%20pmcid:%20pmc5372567. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5372567/from%20pathogenesis%20to%20pharmacogenomics.%20int%20j%20mol%20sci.%202017%20mar%204;18(3):551.%20doi:%2010.3390/ijms18030551.%20pmid:%2028273839;%20pmcid:%20pmc5372567. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5372567/from%20pathogenesis%20to%20pharmacogenomics.%20int%20j%20mol%20sci.%202017%20mar%204;18(3):551.%20doi:%2010.3390/ijms18030551.%20pmid:%2028273839;%20pmcid:%20pmc5372567. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6700650/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6700650/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6700650/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6700650/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6700650/ https://pubmed.ncbi.nlm.nih.gov/24389262/ https://pubmed.ncbi.nlm.nih.gov/24389262/ https://pubmed.ncbi.nlm.nih.gov/24389262/ garcia, et al parkinson’s disease https://doi.org/10.47488/dhrp.v2is2.72 dhr proceedings ǀ http://dhrproceedings.org 120 2022, vol. 2 no. s2 116-121 disord. 2016 jan;22 suppl 1:s119-22. doi: 10.1016/j.parkreldis.2015.09.004. epub 2015 sep 3. pmid: 26372623 17. parkinson’s disease. cleveland clinic. https://my.clevelandclinic.org/health/disease s/8525-parkinsons-disease-an-overview date accessed: 01aug2022 18. national collaborating centre for chronic conditions (uk). parkinson's disease: national clinical guideline for diagnosis and management in primary and secondary care. london: royal college of physicians (uk); 2006. (nice clinical guidelines, no. 35.) 9, non-motor features of parkinson’s disease. available from: https://www.ncbi.nlm.nih.gov/books/nbk4 8501/ 19. parkinson’s disease treatment options. john hopkins medicine. https://www.hopkinsmedicine.org/health/co nditions-and-diseases/parkinsonsdisease/park insons-treatment-options date accessed: 8/1/2022 20. mak, m. k., wong-yu, i. s., shen, x., & chung, c. l. (2017). long-term effects of exercise and physical therapy in people with parkinson disease. nature reviews. neurology, 13(11), 689–703. https://doi.org/10.1038/nrn eurol.2017.128 https://pubmed.ncbi.nlm.nih.gov/29027544/ 21. boucherie, d. m., duarte, g. s., machado, t., faustino, p. r., sampaio, c., rascol, o., & ferreira, j. j. (2021). parkinson's disease drug development since 1999: a story of repurposing and relative success. journal of parkinson's disease, 11(2), 421–429. https://doi.org/10.3233/jpd-202184 https://www.ncbi.nlm.nih.gov/pmc/articles/p mc8150606/#:~:text=a%20large%20attriti on%20rate%20for,by%20the%20fda%20si nce%201999. 22. osborne, j. a., botkin, r., colon-semenza, c., deangelis, t. r., gallardo, o. g., kosakowski, h., martello, j., pradhan, s., rafferty, m., readinger, j. l., whitt, a. l., & ellis, t. d. (2022). physical therapist management of parkinson disease: a clinical practice guideline from the american physical therapy association. physical therapy, 102(4), pzab302. https://doi.org/10.1093/ptj/pzab302 https://www.ncbi.nlm.nih.gov/pmc/articles/p mc9046970/ 23. li, x., zhang, y., wang, y., xu, j., xin, p., meng, y., wang, q., & kuang, h. (2017). the mechanisms of traditional chinese medicine underlying the prevention and treatment of parkinson's disease. frontiers in pharmacology, 8, 634. https://doi.org/10.3389/fphar.2017.00634 24. parkinson’s disease. mayo clinic. https://www.mayoclinic.org/diseasesconditions/parkinsons-disease/diagnosistreatment/drc-20376062 date accessed: 8/1/2022 25. 13 medications to help control parkinson’s disease symptoms. michigan health. https://healthblog.uofmhealth.org/healthmanagement/13-medications-to-helpcontrol-parkinsons-disease-symptoms date accessed: 8/2/2022 26. szatmari, s., illigens, b. m., siepmann, t., pinter, a., takats, a., & bereczki, d. (2017). neuropsychiatric symptoms in untreated parkinson's disease. neuropsychiatric disease and treatment, 13, 815–826. https://doi.org/10.2147/ndt.s130997 27. xu x, fu z, le w. exercise and parkinson's disease. int rev neurobiol. 2019;147:45-74. doi: 10.1016/bs.irn.2019.06.003. epub 2019 jun 20. pmid: 31607362. 28. https://www.healthpartners.com/blog/thebest-exercises-for-parkinsons-disease-andwhy-physical-activity-is-important/ 29. malek n. deep brain stimulation in parkinson's disease. neurol india. 2019 julaug;67(4):968-978. doi: 10.4103/00283886.266268. pmid: 31512617. 30. zahoor i, shafi a, haq e. pharmacological treatment of parkinson’s disease. in: stoker tb, greenland jc, editors. parkinson’s disease: pathogenesis and clinical aspects [internet]. brisbane (au): codon publications; 2018 dec 21. chapter 7. available from: https://www.ncbi.nlm.nih.gov/books/nbk5 36726/ doi: 10.15586/codonpublications.parkinsonsdisea se.2018.ch7 31. patel rs, kamil s, shah mr, bhimanadham nn, imran s. pros and cons of marijuana in treatment of parkinson's disease. cureus. 2019 jun 3;11(6):e4813. doi: 10.7759/cureus.4813. pmid: 31403009; pmcid: pmc6682376. 32. stampanoni bassi m, sancesario a, morace r, centonze d, iezzi e. cannabinoids in parkinson's disease. cannabis cannabinoid https://my.clevelandclinic.org/health/diseases/8525-parkinsons-disease-an-overview https://my.clevelandclinic.org/health/diseases/8525-parkinsons-disease-an-overview https://www.ncbi.nlm.nih.gov/books/nbk48501/ https://www.ncbi.nlm.nih.gov/books/nbk48501/ https://www.hopkinsmedicine.org/health/conditions-and-diseases/parkinsons-disease/parkinsons-treatment-options https://www.hopkinsmedicine.org/health/conditions-and-diseases/parkinsons-disease/parkinsons-treatment-options https://www.hopkinsmedicine.org/health/conditions-and-diseases/parkinsons-disease/parkinsons-treatment-options https://pubmed.ncbi.nlm.nih.gov/29027544/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8150606/#:~:text=a%20large%20attrition%20rate%20for,by%20the%20fda%20since%201999 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8150606/#:~:text=a%20large%20attrition%20rate%20for,by%20the%20fda%20since%201999 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8150606/#:~:text=a%20large%20attrition%20rate%20for,by%20the%20fda%20since%201999 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8150606/#:~:text=a%20large%20attrition%20rate%20for,by%20the%20fda%20since%201999 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc9046970/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc9046970/ https://doi.org/10.3389/fphar.2017.00634 https://www.mayoclinic.org/diseases-conditions/parkinsons-disease/diagnosis-treatment/drc-20376062 https://www.mayoclinic.org/diseases-conditions/parkinsons-disease/diagnosis-treatment/drc-20376062 https://www.mayoclinic.org/diseases-conditions/parkinsons-disease/diagnosis-treatment/drc-20376062 https://healthblog.uofmhealth.org/health-management/13-medications-to-help-control-parkinsons-disease-symptoms https://healthblog.uofmhealth.org/health-management/13-medications-to-help-control-parkinsons-disease-symptoms https://healthblog.uofmhealth.org/health-management/13-medications-to-help-control-parkinsons-disease-symptoms https://doi.org/10.2147/ndt.s130997 https://www.healthpartners.com/blog/the-best-exercises-for-parkinsons-disease-and-why-physical-activity-is-important/ https://www.healthpartners.com/blog/the-best-exercises-for-parkinsons-disease-and-why-physical-activity-is-important/ https://www.healthpartners.com/blog/the-best-exercises-for-parkinsons-disease-and-why-physical-activity-is-important/ https://pubmed.ncbi.nlm.nih.gov/31512617/ https://pubmed.ncbi.nlm.nih.gov/31512617/ https://pubmed.ncbi.nlm.nih.gov/31512617/ https://pubmed.ncbi.nlm.nih.gov/31512617/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://www.ncbi.nlm.nih.gov/books/nbk536726/ https://pubmed.ncbi.nlm.nih.gov/31403009/ https://pubmed.ncbi.nlm.nih.gov/31403009/ https://pubmed.ncbi.nlm.nih.gov/31403009/ https://pubmed.ncbi.nlm.nih.gov/31403009/ https://pubmed.ncbi.nlm.nih.gov/31403009/ https://pubmed.ncbi.nlm.nih.gov/31403009/ https://pubmed.ncbi.nlm.nih.gov/28861502/ https://pubmed.ncbi.nlm.nih.gov/28861502/ https://pubmed.ncbi.nlm.nih.gov/28861502/ garcia, et al parkinson’s disease https://doi.org/10.47488/dhrp.v2is2.72 dhr proceedings ǀ http://dhrproceedings.org 121 2022, vol. 2 no. s2 116-121 res. 2017 feb 1;2(1):21-29. doi: 10.1089/can.2017.0002. pmid: 28861502; pmcid: pmc5436333. 33. mcfarthing k, rafaloff g, baptista mas, wyse rk, stott srw. parkinson's disease drug therapies in the clinical trial pipeline: 2021 update. j parkinsons dis. 2021;11(3):891-903. doi: 10.3233/jpd219006. pmid: 34151864; pmcid: pmc8461678. https://pubmed.ncbi.nlm.nih.gov/28861502/ https://pubmed.ncbi.nlm.nih.gov/28861502/ https://pubmed.ncbi.nlm.nih.gov/28861502/ special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.98 dhr proceedings ǀ http://dhrproceedings.org 87 2023, vol. 2 no. s2 87-92 commentary psychological effect of domestic abuse on children during covid lilian sustayta1,2, odalis rodriguez1,2, genesis garza1,2 , mia leal1,3, sammi arafat1,3, evelyn sanchez1,4, keina nunez1,4, alexxa garcia1,5, emily chavez1,5, rebecca lerma1,6, gabriela perez1,6 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 economedes high school, edinburg, tx 3 mcallen memorial high school, mcallen ,tx 4 mercedes high school, mercedes, tx 5 mercedes early college high school, mercedes, tx 6 zapata high school, zapata, tx received: november 2, 2023 accepted for publication: november 3, 2023 published: november 16, 2023 introduction the covid-19 pandemic has had a detrimental impact on the lives of many children, particularly within their own homes. this influence has been predominantly negative, leading to various challenges such as isolation and domestic problems within households. the limitations imposed as a response to the pandemic resulted in children being confined to dysfunctional environments, thereby exacerbating the prevalence of abuse.1 domestic abuse, commonly known as "domestic violence," encompasses a range of behaviors aimed at establishing and maintaining control and power over another person. this abuse can manifest in various forms, including physical, sexual, emotional, economic, and psychological actions or threats against an individual. such actions may include tactics intended to instill fear, intimidation, manipulation, injury, humiliation, blame, or wound the victim.2 domestic abuse has various effects on people, including increased anxiety, depression, eating disorders, and sleep issues. children who experience domestic abuse may feel hopeless, unmotivated, and struggle to express their emotions. our study is aiming to show the increase in domestic abuse during and post covid-19. childhood significance during childhood, one's personality and behavior is in its most important stage of development. children suffering from an unhealthy relationship are shown to have difficulty building relationships with others.3 when parents neglect their children, children can be exposed to social and emotional consequences. when adolescents are treated with neglect and do not receive proper care, they will be exposed to mental illnesses such as depression, anxiety, and suicidal behaviors.3 active skills are in the most important process of development. experiencing abuse and violence has an immense influence on one's mental development. violence affects the physical, mental, and social health of an individual. children are required to have a stable and safe environment for proper mental development. the occurrence of domestic violence disrupts the balance of the family system and members of the family suffer the consequences.3 domestic abuse incidence during the pandemic according to the national commission on covid-19 and criminal justice reports, domestic special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.98 dhr proceedings ǀ http://dhrproceedings.org 88 2023, vol. 2 no. s2 87-92 abuse increased by 8.1 % due to the lockdown orders that were established in 2020.4 reports done by the national commission on covid-19 and criminal justice show that, out of 18 studies, 12 in the united states and 6 in other countries, the rate of domestic abuse increased by 7.9% over all and increased by 8.1% in the united states.4 data was collected from logs, police calls, emergency lines, and health records, along with other administrative logs. reasons for the domestic abuse increase were financial issues, substance abuse and wrong coping mechanisms.4 studies done by the us davis health, show that fewer reports of child abuse during covid-19 pandemic which may lead to believe abuse reports were missed during distance learning.5 their studies indicate that although there may have been a rise in domestic abuse though it was not reported. julia magana said that since the world shut down it caused adults to feel stressed and isolated which set up the rise of domestic abuse.5 magana teamed up with colleagues from pediatric emergency care applied research network (pecarn) to conduct a study that was published in the journal of the american academy of pediatrics that consisted of over 1.5 million emergency department encounters at nine children's hospitals.5 they conducted their study by identifying abuse in three methods: child physical abuse diagnoses among all ages, age-restricted high-risk injury, or agerestricted skeletal survey completion. the primary outcomes were encounter rates per day and clinical severity before and during the covid-19 pandemic. across the three methods used, they identified about 10,000 relevant encounters. the rate for physical abuse diagnoses overall, per day, decreased by 19% during the time of the pandemic. the decrease was seen in children aged 2-13 years old, but less for young children under two years old and older children over 13. for age-restricted high-risk injury encounters, diagnosis declined by 10% during the pandemic. of note, this reduction was in low severity abuse cases and not in severe abuse. finally, there was no decrease in total collection of skeletal survey numbers, though there was a reduction in low severity encounters identified by this method with no change in high severity.5 the world health organization states that a third of children have experienced violence, which is approximately 55 million children who are abused or were abused(6). during the covid-19 pandemic, there were a total of 616 reports of domestic violence (sexual and physical) with ages ranging from 5 to 9 and 14 to 18 with two deaths related to the violence. most cases were female victims, of which 76.7% reported abuse from family members, 23.3% was made up of males, and many were children(6). many of the reports came from the victim’s own home, with sexual abuse coming out on top as the highest it has ever been. the most common offenders were males, including fathers, grandparents, and brothers. self inflicted injuries also increased during covid-19, corresponding to 67% of the total reported cases of domestic abuse and were mostly common in females.6 the world health organization states that a third of children have experienced violence, which is approximately 55 million children who are abused or were abused.6 covid caused many parents to lose their jobs, and some worked from home which caused the % of domestic violence incidence to increase 12%.3 a study shows that the first abuse incidents increased from 16% to 23% and it also shows that it's linked to the parent’s job loss.3 the statistics show that 60% of children under the age of 17 in the usa suffer some kind of domestic violence.3 suicide rates in children who experience domestic violence children who experience maltreatment throughout their lifetime are more prone to dealing with mental health issues.7 because they are more vulnerable, abuse can often lead to self-destructive behavior within their bodies such as substance abuse, impulsivity and disorders like bipolar disorder, post traumatic stress disorder, and severe cases of psychosis.7 these are common patterns seen within domestic abuse victims. although there are some exceptions, this trauma begins to interfere with the everyday lives of these children as physical methods of relief are only the beginning, like self–harm.8 selfharm is seen as an alternative form of pain for the psychological toll they are experiencing as these children rather indulge in this physical harm to distract them from their psychological pain and needs.9 this emotional distress comes with factors such as doubts of self-worth and suicidal tendencies. a study done with over 11,000 9-10 year olds showcases how 9.1 % of them indulge in self-harming activities including 1.3% increase in suicidal tendencies and/or attempts.10 these signs of self-destructive behavior often go unnoticed by parents as well as domestic perpetrators. as much as 88% of parents claimed to be unaware of their child’s mental health condition.10 because there is such a high rate in self-destructing behavior without appropriate help, suicide can seem like the next step children take in order to put an end to their issues. this has increased the number of suicides within children of the age groups of 5-11 years, to the point they have special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.98 dhr proceedings ǀ http://dhrproceedings.org 89 2023, vol. 2 no. s2 87-92 risen to become the 8th leading cause of death.11 these suicide rates can be linked back to the issue of domestic abuse, the more trauma that a child experiences, the more likely they are to seek these alternatives. it has even been studied that children who experience 7 or more household traumatic events have a 31.1% of attempting suicide.12 the increase of traumatic events continues to put the lives of children at risk. the rise in demand for child therapy since covid throughout the covid-19 pandemic, the quality of people's home lives and mental health remained a mystery as it was a period of unpredictability, since most people had not yet experienced something as intense as a quarantine before. it was a crucial period, consisting of disruptive situations that were experienced by adolescents and children alike. the extent to which covid-19 has affected kids has proven to be impactful in terms of the quarantine mandate and the closing down of schools. this resulted in a decrease of social interactions, therefore a state of vulnerability and isolation. since the pandemic, the after effects of covid-19 have remained in our community. people under the age of 18 have been severely affected due to the drastic amount of anxiety and depression symptoms found in the new generation in recent times causing a national need for anxiety and depression medication and treatment.13 psychologists claim that mental health has become a world-wide phenomenon compared to that of past years before covid-19. more than 8 in 10 (84%) psychologists who treat anxiety disorders said they have seen an increase in demand for anxiety treatment since the start of the pandemic, compared with 74% a year ago.13 demand for treatment of depression is also up, with 72% of psychologists who treat depressive disorders saying they have seen an increase, compared with 60% in 2020.13 this data shows the lack of quality services and equitable delivery in the medical field.14 risk factors in order to determine the best measures to take in preventing future cases of domestic abuse, it is crucial to analyze and assess the risk factors that increase the chances of such cases occurring. risk factors are characteristics of either a parent or guardian, or the child themselves that can increase the possibility of abuse cases.15 it is important to note that risk factors are not direct causes of violence against youth, however, they can be linked to such cases.16 risk factors fall into various categories including individual, community, social, and family. table 1. individual  participation in substances such as tobacco, alcohol, and drugs  being exposed to violence and family discord  reduced educational levels  being disabled or suffering from mental health issues community  poverty  easy accessibility to liquor and narcotics  lesser economic possibilities  high gang activity and drug trafficking concentrations social  social and gender expectations that promote a culture of violence  health, financial, educational, and social policies that uphold economic, gender, and social disparities  peer rejection in society family  drug usage or criminal activity on the part of parents  weak emotional connection between parents and children  severe, inadequate or disorganized disciplinary measures  involuntary or premature marriage reference: increase risk during covid-19 in march and april of 2020, government leaders made the decision to enforce stay-at-home and shelter-in-place orders in hopes of regulating the covid-19 pandemic. while the initial orders worked to contain the spread of the coronavirus, these factors would lead to an increase in other adverse outcomes, such as a rise in domestic violence and child abuse cases. because of mandated isolation as well as the economic effects of the pandemic, factors that tend to be associated with abuse cases were augmented. such factors included rising economic instability, increased stress related to childcare and homeschooling, greater male unemployment rates, and inadequate coping mechanisms, such as increased drinking and other substance use.17 furthermore, because of both children and adults being forced to remain in their homes, the social network of teachers, friends, neighbors, and special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.98 dhr proceedings ǀ http://dhrproceedings.org 90 2023, vol. 2 no. s2 87-92 others who could potentially report or intervene in cases of abuse were cut off. after the imposition of stay-at-home order, cases of domestic abuse increased by 7.9 % on average in studies including both the u.s and international countries. in the u.s alone, the reports of domestic violence increased by 8.1% during the pandemic.17 prevention domestic abuse is a complicated issue that traces a foundation in unhealthy relationships and harmful living conditions.15. because the problem can be characterized by having both internal and external stimuli, as well as an imbalance of power between child and perpetrator.17 prevention works more to try and attack the problem at the root, taking systematic consideration of the risk factors associated with it. for many organizations, the goal towards prevention begins at not only an interpersonal level, but also with legal and federal actions.18 inspire concerned by the rising cases of abuse during isolation, 21 leaders of worldwide organizations, including unicef, un women, and the world health organization, united in 2016 under one shared goal of protecting children from violence. they signed a joint leader’s statement expressing their concern for the heightened abuse cases that were negatively impacting children. in doing so, they established their plan to work with local and federal governments as well as urging communities and the leaders of every sector to unite against the growing instances of abuse in order to achieve the unanimous objective of ending all kinds of violence and neglect towards children.18 under the leadership of the world health organization, inspire offers seven evidence-based strategies that have shown to be effective in preventing child abuse.18 the seven strategies are: ● implementation and enforcement of laws; ● norms and values; ● safe environments; ● parental and caregiver support; ● income and economic strengthening; ● response services provision and; ● education and life skills figure 1. count of all cps reports and percent with dv alleged by week and year.19 figure 2. percentage of cps reports with dv alleged by season.19 figure 3. count of cps reports by reporter type by month.19 conclusion the negative effects of covid-19 still linger in our communities today. having been such a stressful event that occurred in people's lives, its effects were momentous on children as they became more isolated and restricted from the rest of the world compared to everyone else. further yet, the scars left on the children were cut deeper on those who experienced domestic violence as they dealt with the abuse and the effects of covid-19. the pressure put special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.98 dhr proceedings ǀ http://dhrproceedings.org 91 2023, vol. 2 no. s2 87-92 on families during this time made for already precarious households to become even more unstable, making it an even more difficult environment for a child to thrive in. the traumatic scenes that some children witnessed and endured made it possible for mental issues to develop such as anxiety, depression, p.t.s.d, etc. even after quarantine was over, domestic violence rates are still at an all time high, causing a child's development to have serious repercussions in the future, including mental health. despite the rise in cases, organizations like inspire continue to work together with local governments to create a future for children that is safe. in addition, the family crisis center in the rio grande valley has also helped combat this by changing the lives of many through providing intervention and prevention services to children no matter their circumstances. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. vidal s, prince d, connell cm, caron cm, kaufman js, tebes jk. maltreatment, family environment, and social risk factors: determinants of the child welfare to juvenile justice transition among maltreated children and adolescents. child abuse negl. 2017.jan;63:7-18. doi: 10.1016/j.chiabu.2016.11.013. epub 2016 nov 22. pmid: 27886518; pmcid: pmc5283859. 2. øverlien c. the covid-19 pandemic and its impact on children in domestic violence refuges. child abuse rev. 2020;29(4):379386. doi:10.1002/car.2650 3. grzejszczak j, gabryelska a, gmitrowicz a, kotlicka-antczak m, strzelecki d. are children harmed by being locked up at home? the impact of isolation during the covid-19 pandemic on the phenomenon of domestic violence. int j environ res public health. 2022 oct 27;19(21):13958. doi: 10.3390/ijerph192113958. pmid: 36360840; pmcid: pmc9657348. 4. 1.warren j. new analysis shows 8% increase in u.s. domestic violence incidents following pandemic stay-at-home orders. council on criminal justice. published february 24, 2021. https://counciloncj.org/new-analysis-shows8-increase-in-u-s-domestic-violenceincidents-following-pandemic-stay-at-homeorders/ 5. 1.news. study finds fewer reports of child physical abuse during covid-19 pandemic. news. https://health.ucdavis.edu/news/headlines/st udy-finds-fewer-reports-of-child-physicalabuse-during-covid-19-pandemic/2022/07 6. de oliveira, stela maria tavolieri et al. “epidemiological study of violence against children and its increase during the covid19 pandemic.” international journal of environmental research and public health vol. 18,19 10061. 24 sep. 2021, doi:10.3390/ijerph181910061 7. shain b. suicide and suicide attempts in adolescents. pediatrics. 2016;138(1):e20161420-e20161420. doi:https://doi.org/10.1542/peds.2016-1420 8. perepletchikova f, kaufman j. emotional and behavioral sequelae of childhood maltreatment. current opinion in pediatrics. published online august 2010:1. doi:https://doi.org/10.1097/mop.0b013e3283 3e148a 9. cutting and self-harm: why it happens and what to do. harvard health. published may 31, 2023. https://www.health.harvard.edu/blog/cutting -and-self-harm-why-it-happens-and-what-todo-202305312940 10. kingkade t, chuck e. suicidal thoughts are increasing in young kids, experts say. it began before the pandemic. nbc news. published april 8, 2021. https://www.nbcnews.com/news/usnews/suicidal-thoughts-are-increasingyoung-kids-experts-say-it-began-n1263347 11. understanding the characteristics of suicide in young children. national institute of mental health (nimh). published december 14, 2021. https://www.nimh.nih.gov/news/sciencenews/2021/understanding-thecharacteristics-of-suicide-in-youngchildren#:~:text=trauma%2c%20including https://counciloncj.org/new-analysis-shows-8-increase-in-u-s-domestic-violence-incidents-following-pandemic-stay-at-home-orders/ https://counciloncj.org/new-analysis-shows-8-increase-in-u-s-domestic-violence-incidents-following-pandemic-stay-at-home-orders/ https://counciloncj.org/new-analysis-shows-8-increase-in-u-s-domestic-violence-incidents-following-pandemic-stay-at-home-orders/ https://counciloncj.org/new-analysis-shows-8-increase-in-u-s-domestic-violence-incidents-following-pandemic-stay-at-home-orders/ https://health.ucdavis.edu/news/headlines/study-finds-fewer-reports-of-child-physical-abuse-during-covid-19-pandemic/2022/07 https://health.ucdavis.edu/news/headlines/study-finds-fewer-reports-of-child-physical-abuse-during-covid-19-pandemic/2022/07 https://health.ucdavis.edu/news/headlines/study-finds-fewer-reports-of-child-physical-abuse-during-covid-19-pandemic/2022/07 https://doi.org/10.1542/peds.2016-1420 https://doi.org/10.1097/mop.0b013e32833e148a https://doi.org/10.1097/mop.0b013e32833e148a https://www.health.harvard.edu/blog/cutting-and-self-harm-why-it-happens-and-what-to-do-202305312940 https://www.health.harvard.edu/blog/cutting-and-self-harm-why-it-happens-and-what-to-do-202305312940 https://www.health.harvard.edu/blog/cutting-and-self-harm-why-it-happens-and-what-to-do-202305312940 https://www.nbcnews.com/news/us-news/suicidal-thoughts-are-increasing-young-kids-experts-say-it-began-n1263347 https://www.nbcnews.com/news/us-news/suicidal-thoughts-are-increasing-young-kids-experts-say-it-began-n1263347 https://www.nbcnews.com/news/us-news/suicidal-thoughts-are-increasing-young-kids-experts-say-it-began-n1263347 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.98 dhr proceedings ǀ http://dhrproceedings.org 92 2023, vol. 2 no. s2 87-92 %20suspected%20or%20confirmed%20case s%20of%20chavira da, ponting c, ramos g. the impact of covid-19 on child and adolescent mental health and treatment considerations. behav res ther. 2022 oct;157:104169. doi: 10.1016/j.brat.2022.104169. epub 2022 jul 31. pmid: 35970084; pmcid: pmc9339162.abuse%2c 12. dube sr, anda rf, felitti vj, chapman dp, williamson df, giles wh. childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span. jama. 2001;286(24):3089. doi:https://doi.org/10.1001/jama.286.24.308 9 13. chavira da, ponting c, ramos g. the impact of covid-19 on child and adolescent mental oct;157:104169. doi: 10.1016/j.brat.2022.104169. epub 2022 jul 31. pmid: 35970084; pmcid: pmc9339162. 14. apa.org. published 2022. https://www.apa.org/news/press/releases/20 21/10/mental-health-treatmentdemand#:~:text=more%20than%208%20in %2010 15. world health organization. violence against children. who.int. published june 8, 2020. https://www.who.int/news-room/factsheets/detail/violence-against-children 16. centers for disease control and prevention. risk and protective factors. centers for disease control and prevention. published march 2, 2020. https://www.cdc.gov/violenceprevention/yo uthviolence/riskprotectivefactors.html 17. piquerox ar, jennings wg, jemison e, kaukinen c, knaul fm. domestic violence during covid-19: evidence from a systematic review and metaanalysis.washington, d.c.: council on criminal justice, published march 2021 https://build.neoninspire.com/counciloncj/w pcontent/uploads/sites/96/2021/07/domesticviolence-during-covid-19-february2021.pdf 18. inspire | end violence. (n.d.). end violence against children. https://www.endviolence.org/inspire 19. rebbe r, lyons vh, webster d, putnamhornstein e. domestic violence alleged in california child maltreatment reports during the covid-19 pandemic. j fam violence. 2022;37(7):1041-1048. doi:10.1007/s10896-021-00344-8. https://pubmed.ncbi.nlm.nih.gov/34866773/ https://www.who.int/news-room/fact-sheets/detail/violence-against-children https://www.who.int/news-room/fact-sheets/detail/violence-against-children https://www.cdc.gov/violenceprevention/youthviolence/riskprotectivefactors.html https://www.cdc.gov/violenceprevention/youthviolence/riskprotectivefactors.html https://build.neoninspire.com/counciloncj/wp-content/uploads/sites/96/2021/07/domestic-violence-during-covid-19-february-2021.pdf https://build.neoninspire.com/counciloncj/wp-content/uploads/sites/96/2021/07/domestic-violence-during-covid-19-february-2021.pdf https://build.neoninspire.com/counciloncj/wp-content/uploads/sites/96/2021/07/domestic-violence-during-covid-19-february-2021.pdf https://build.neoninspire.com/counciloncj/wp-content/uploads/sites/96/2021/07/domestic-violence-during-covid-19-february-2021.pdf https://build.neoninspire.com/counciloncj/wp-content/uploads/sites/96/2021/07/domestic-violence-during-covid-19-february-2021.pdf https://www.end-violence.org/inspire https://www.end-violence.org/inspire special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.1 dhr proceedings ǀ http://dhrproceedings.org 1 2024, vol. 4 no. s2 pg. 1-7 manuscript the role of microplastics in male fertility decline: a review of hispanic populations along the texas-mexico border marisol acosta1, jocelyn b. armendariz1,2, juan l. flores 1,3, daniella e. guerrero1,3, teresa j. hidalgo1,2, jessica a. lópez1,2, leonel a. nuñez1,2, and angie j. ruiz1,2 1dhr health high school and community outreach 2 south texas isd health professions 3 south texas isd medical professions received: july 3, 2024 accepted for publication: january 24, 2025 introduction the pervasive presence of microplastics in the environment poses a significant threat to human health, including reproductive health.1,3 this literature review focuses on the emerging evidence linking microplastic exposure to male fertility decline, specifically examining studies involving hispanic populations along the texas-mexico border. this region presents a unique context due to factors such as high rates of environmental pollution, potential disparities in healthcare access, and cultural practices influencing exposure.4,6 the review will systematically evaluate existing research, identify knowledge gaps, and highlight the need for future studies tailored to this vulnerable population. understanding the impact of microplastics on male fertility within this specific demographic is critical for developing targeted public health interventions. microplastics and male reproductive health: a general overview microplastics, defined as plastic particles less than 5 mm in diameter, are ubiquitous pollutants found in various environmental matrices, including air, water, and soil.2,7 human exposure occurs through ingestion, inhalation, and dermal contact, leading to microplastic accumulation in various organs, including reproductive tissues.1, 8-9 several studies have demonstrated the adverse effects of microplastics on male reproductive health in both animal models and humans.10,12 these effects include reduced sperm motility, altered sperm morphology, decreased sperm count, and increased oxidative stress.1,13-14 the mechanisms underlying these effects are not fully understood but may involve oxidative stress, inflammation, and hormonal disruption.1,14 furthermore, the type and concentration of microplastics, along with individual susceptibility, may influence the severity of the effects.8 a study by hu et al. found microplastics in both canine and human testes, highlighting the pervasive nature of this contamination.8 the study also http://dhrproceedings.org/ special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.1 dhr proceedings ǀ http://dhrproceedings.org 2 2024, vol. 4 no. s2 pg. 1-7 revealed a negative correlation between specific polymers (pvc and pet) and testis weight, suggesting a potential link between microplastic exposure and impaired testicular function. the texas-mexico border: a unique context for microplastic exposure the texas-mexico border region presents a unique epidemiological setting for studying the impact of microplastics on male fertility. this region faces several challenges that may exacerbate exposure and increase vulnerability to adverse health outcomes. firstly, the area experiences high levels of environmental pollution, including air and water contamination, potentially leading to increased microplastic exposure compared to other regions.15,16 secondly, the region’s socio-economic disparities, including limited healthcare access and high rates of poverty, may hinder early diagnosis and treatment of fertility problems.4,6 thirdly, cultural practices and dietary habits within hispanic communities along the border may influence exposure pathways and susceptibility to microplastic-related health effects. further research is needed to investigate these factors in detail and assess their combined impact on male fertility outcomes.17 research gaps and methodological considerations despite the growing concern, there is a significant lack of research specifically investigating the impact of microplastics on male fertility within hispanic populations along the texas-mexico border. most existing studies are either broad-based, examining general populations without considering specific demographic factors, or focus on other environmental pollutants impacting male fertility.18-20 furthermore, there are methodological challenges in accurately assessing microplastic exposure and its effects. quantifying microplastic levels in human tissues requires advanced techniques, such as pyrolysis-gas chromatography/mass spectrometry (py-gc/ms), which may not be readily available for large-scale epidemiological studies.8,9 moreover, establishing a causal link between microplastic exposure and fertility decline requires robust epidemiological designs that account for confounding factors, such as lifestyle, diet, and other environmental exposures.19 studies should also consider the potential synergistic effects of microplastics with other environmental pollutants, as individuals in this region are likely exposed to a complex mixture of contaminants.14 future research directions addressing the research gaps requires a multidisciplinary approach involving environmental scientists, epidemiologists, reproductive health specialists, and community health workers. future research should prioritize the following: targeted epidemiological studies: conduct large-scale epidemiological studies specifically focusing on hispanic men along the texas-mexico border. measure microplastic exposure levels (e.g., through blood, semen, or urine samples) and assess their association with various fertility parameters, including sperm count, motility, morphology, and dna integrity. these studies should employ advanced statistical methods to adjust for potential confounders and investigate dose-response relationships.8,9 http://dhrproceedings.org/ special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.1 dhr proceedings ǀ http://dhrproceedings.org 3 2024, vol. 4 no. s2 pg. 1-7 mechanistic studies: investigate the biological mechanisms through which microplastics affect male reproductive health. this could involve in vitro studies using human sperm cells exposed to different types and concentrations of microplastics, examining changes in gene expression, oxidative stress markers, and other relevant biomarkers.21,22 animal models could also be used to study the long-term effects of microplastic exposure on testicular development and function.10,11 community-based participatory research: engage hispanic communities along the border in the research process to ensure culturally appropriate data collection methods and address potential barriers to participation. this approach can improve the relevance and impact of research findings.23 exposure assessment: develop robust methods for assessing microplastic exposure in this population, considering diverse exposure pathways (e.g., diet, water consumption, air inhalation) and accounting for potential differences in exposure based on occupation, lifestyle, and residential location.24 synergistic effects: investigate the potential synergistic effects of microplastic exposure with other environmental pollutants commonly found in the region, such as heavy metals and pesticides, to better understand the cumulative impact on male reproductive health.25-26 policy implications: translate research findings into actionable policy recommendations to reduce microplastic pollution, improve healthcare access, and promote reproductive health within hispanic communities along the texas-mexico border. conclusion the evidence suggests a potential link between microplastic exposure and male fertility decline. however, more research is needed to understand the specific impact on hispanic populations along the texas-mexico border. this region's unique environmental and socio-economic context warrants targeted studies that consider the interplay of multiple factors influencing male reproductive health. by addressing the identified research gaps and employing a communityengaged approach, future investigations can provide critical information for developing effective public health interventions to protect the reproductive health of this vulnerable population. furthermore, understanding the role of microplastics in this context can contribute to broader efforts to mitigate the global health impacts of plastic pollution. the potential for transgenerational effects of microplastic exposure also necessitates long-term monitoring and investigation to fully understand the long-term health consequences. the alarming decline in male fertility rates globally and the potential contribution of environmental factors such as microplastics underscores the urgent need for further research and targeted public health initiatives. the combination of environmental exposures and socio-economic factors in regions like the texas-mexico border highlights the need for a holistic approach to address male fertility decline, considering lifestyle modifications, environmental interventions, and healthcare access improvements. the potential for nutraceuticals to mitigate the negative impact of environmental factors on male fertility warrants further investigation as a potential supplementary approach. the study of delayed diagnosis of tuberculosis in the region also points to broader healthcare access issues that may affect the timely diagnosis and treatment of fertility problems related to microplastic exposure. the impact of economic uncertainty on male fertility further complicates http://dhrproceedings.org/ special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.1 dhr proceedings ǀ http://dhrproceedings.org 4 2024, vol. 4 no. s2 pg. 1-7 the picture, highlighting the interplay of social and economic factors in reproductive health outcomes. finally, the consideration of cultural practices and herbal product use within the hispanic community is essential for developing culturally sensitive public health interventions. acknowledgements nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. funding: funded by dhr health high school and community outreach; dhr health; south texas independent school district. references 1. microplastics and fertility | exon publications. doi.org. published 2024. accessed january 21, 2025. https://doi.org/10.36255/microplastics-fertility 2. landrigan pj. human health and ocean pollution. annals of global health. 2020;86(1):151. doi:https://doi.org/10.5334/aogh.2831 3. landrigan pj, raps h, cropper m, et al. the minderoo-monaco commission on plastics and human health. annals of global health. 2023;89(1). doi:https://doi.org/10.5334/aogh.4056 4. valentine sampson alia, ed wong alvarado, diaz em, reinhart h. fri520 disparities in available surgeons and specialty physicians providing endocrinerelated health care coverage to populations in south texas and the rio grande valley. journal of the endocrine society. 2023;7(supplement_1). doi:https://doi.org/10.1210/jendso/bvad114.1865 5. forero-quintana a, grineski se. delayed diagnosis of tuberculosis in the u.s.mexico border region: a health narratives approach. research in the sociology of health care. published online january 2012:45-65. doi:https://doi.org/10.1108/s02754959(2012)0000030005 6. essigmann ht, aguilar da, perkison wb, et al. epidemiology of antibiotic use and drivers of cross-border procurement in a mexican american border community. frontiers in public health. 2022;10. doi:https://doi.org/10.3389/fpubh.2022.832266 7. de sales-ribeiro c, brito-casillas y, fernandez a, caballero mj. an end to the controversy over the microscopic detection and effects of pristine microplastics in fish organs. scientific reports. 2020;10(1). doi:https://doi.org/10.1038/s41598-02069062-3 8. chelin jamie hu, garcia ma, nihart a, et al. microplastic presence in dog and human testis and its potential association with sperm count and weights of testis and http://dhrproceedings.org/ special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.1 dhr proceedings ǀ http://dhrproceedings.org 5 2024, vol. 4 no. s2 pg. 1-7 epididymis. toxicological sciences. 2024;200(2). doi:https://doi.org/10.1093/toxsci/kfae060 9. l weina, h yena, liang h, huan z, gang l, ge l. p-762 discovery and quantification of microplastics in human cumulus granulosa cells. human reproduction. 2024;39(supplement_1). doi:https://doi.org/10.1093/humrep/deae108.1081 10. dibona er, haley c, geist sj, seemann f. developmental polyethylene microplastic fiber exposure entails subtle reproductive impacts in juvenile japanese medaka ( oryzias latipes ). environmental toxicology and chemistry. 2022;41(11):2848-2858. doi:https://doi.org/10.1002/etc.5456 11. sun z, wu b, yi j, et al. impacts of environmental concentrations of nanoplastics on zebrafish neurobehavior and reproductive toxicity. toxics. 2024;12(8):617-617. doi:https://doi.org/10.3390/toxics12080617 12. simran kauts, mishra y, singh mp. impact of polyethylene terephthalate microplastics on drosophila melanogaster biological profiles and heat shock protein levels. biology. 2024;13(5):293-293. doi:https://doi.org/10.3390/biology13050293 13. cai t, boeri l, miacola c, et al. can nutraceuticals counteract the detrimental effects of the environment on male fertility? a parallel systematic review and expert opinion. minerva endocrinology. published online september 2024. doi:https://doi.org/10.23736/s2724-6507.24.04218-0 14. mohajer n, culty m. impact of human-relevant doses of endocrine disrupting chemical and drug mixtures on testis development and function. reproduction. published online october 1, 2024. doi:https://doi.org/10.1530/rep-24-0155 15. dávila gh. joint air pollution sampling program in twin cities on the u.s.-mexico border. pubmed. 1976;10(3):241-246. 16. pinakana sd, mendez e, ibrahim i, majumder ms, raysoni au. air pollution in south texas: a short communication of health risks and implications. air. 2023;1(2):94103. doi:https://doi.org/10.3390/air1020008 17. levario ma. fevered measures: public health and race at the texas-mexico border, 1848–1942 by john mckiernan-gonzález (review). southwestern historical quarterly. 2013;117(1):100-101. doi:https://doi.org/10.1353/swh.2013.0067 18. kerna na. an overview of the causes and consequences of male fertility decline. perceptions in reproductive medicine. 2019;3(1). doi:https://doi.org/10.31031/prm.2019.02.000555 19. skakkebaek ne, rajpert-de meyts e, buck louis gm, et al. male reproductive disorders and fertility trends: influences of environment and genetic susceptibility. physiological reviews. 2016;96(1):55-97. doi:https://doi.org/10.1152/physrev.00017.2015 http://dhrproceedings.org/ special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.1 dhr proceedings ǀ http://dhrproceedings.org 6 2024, vol. 4 no. s2 pg. 1-7 20. damilare rotimi, shio kumar singh. implications of lifestyle factors on male reproductive health. jbra. published online january 1, 2024. doi:https://doi.org/10.5935/1518-0557.20240007 21. henriques mc, santiago j, patrício a, herdeiro mt, loureiro s, fardilha m. smoking induces a decline in semen quality and the activation of stress response pathways in sperm. antioxidants. 2023;12(10):1828. doi:https://doi.org/10.3390/antiox12101828 22. santiago j, silva jv, santos mas, fardilha m. the ageing sperm: molecular mechanisms underlying the age-associated decline in human sperm quality. human reproduction. 2022;37(supplement_1). doi:https://doi.org/10.1093/humrep/deac107.110 23. parker a, johnson-motoyama m, mariscal es, guilamo-ramos v, reynoso e, fernandez c. novel service delivery approach to address reproductive health disparities within immigrant latino communities in geographic hot spots: an implementation study. health and social work. 2020;45(3). doi:https://doi.org/10.1093/hsw/hlaa014 24. metzger r, delgado j, herrell r. environmental health and hispanic children. environmental health perspectives. 1995;103(suppl 6):25-32. doi:https://doi.org/10.1289/ehp.95103s625 25. montano l, maugeri a, volpe mg, et al. mediterranean diet as a shield against male infertility and cancer risk induced by environmental pollutants: a focus on flavonoids. international journal of molecular sciences. 2022;23(3):1568. doi:https://doi.org/10.3390/ijms23031568 26. wirth jj, mijal rs. adverse effects of low level heavy metal exposure on male reproductive function. systems biology in reproductive medicine. 2010;56(2):147167. doi:https://doi.org/10.3109/19396360903582216 27. hunt kn, kelly ag, faubion l, et al. fertility knowledge and educational experiences of graduating medical students: a multi-institution survey. journal of women’s health. 2024;33(8). doi:https://doi.org/10.1089/jwh.2023.1016 28. f farlie. o-174 marginal gains: can small actions in the art lab improve the environmental impact of medically assisted reproduction? human reproduction. 2024;39(supplement_1). doi:https://doi.org/10.1093/humrep/deae108.203 29. strazzullo m, matarazzo mr. epigenetic effects of environmental chemicals on reproductive biology. current drug targets. 2017;18(10). doi:https://doi.org/10.2174/1389450117666161025100125 30. aitken j. the decline and fall of human fertility. fertility & reproduction. 2023;05(04):230-230. doi:https://doi.org/10.1142/s2661318223740444 http://dhrproceedings.org/ special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.1 dhr proceedings ǀ http://dhrproceedings.org 7 2024, vol. 4 no. s2 pg. 1-7 31. tennenbaum sr, bortner r, lynch c, et al. epigenetic changes to gene pathways linked to male fertility in ex situ black‐footed ferrets. evolutionary applications. 2024;17(1). doi:https://doi.org/10.1111/eva.13634 32. nahata l, stanek cj, theroux ci, olsavsky al, quinn gp, creary se. fertility testing knowledge and attitudes in male adolescents and young adults with scd and their caregivers: a pilot study. blood advances. 2022;6(12):3703-3706. doi:https://doi.org/10.1182/bloodadvances.2022007004 33. hellstrand j, nisén j, myrskylä m. economic uncertainty and men’s fertility: analysing the 2010s fertility decline in finland by field of education and employment characteristics. max planck institute for demographic research. published online january 2025. doi:https://doi.org/10.4054/mpidr-wp-2025-001 34. rivera jo, gonzález-stuart a, ortiz m, rodríguez jc, anaya jp, meza a. guide for herbal product use by mexican americans in the largest texas-mexico border community. pubmed. 2006;102(2):46-56. http://dhrproceedings.org/ special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.87 dhr proceedings ǀ http://dhrproceedings.org 33 2023, vol. 2 no. s2 33-39 commentary the long-term impacts of domestic abuse on hispanics in their teens nick a. costilla1,2, mireya j. eligio1,2, hector jalomo1,3, debra l. m. limon1,3, leyla a. medrano1,2, valeria j. muniz1,3, mariah perez1,3, isabelle l. perez1,3, melissa sosa1,2, heidi a. vazquez1,2, savannah s. villarreal1,2 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 los fresnos high school, los fresnos, tx 3 san benito high school, san benito, tx received: june 29, 2023 accepted for publication: september 26, 2023 published: november 16, 2023 introduction domestic violence/abuse affects an estimated 10 million people every year, yet it is one of the least reported incidents.1 domestic abuse includes maltreatment economically, sexually, physically, emotionally, and psychologically.1 although awareness for victims of domestic abuse has been on the rise, awareness in the hispanic community has been at a constant low. in the hispanic community, cultural and religious practices create a greater challenge for people who want to reach out about the abuse they are experiencing. machismo and familismo are two examples of cultural standards that prevent many from reaching out and reporting abusive situations.2 studies also show that lower education levels correlate to a higher risk of domestic violence.2 additionally, witnessing and experiencing abuse in childhood has been associated with becoming a perpetrator of domestic violence.1 awareness, education, and self-help has been shown to be an effective countermeasure for domestic abuse; therefore, knowledge on the long-term impacts of domestic abuse is important to disseminate among hispanic teens. factors leading to domestic abuse hispanics reported higher rates of intimate partner violence. a majority of hispanics have suffered partner violence (58%). in contrast 52% of african american and 37% of caucasians have had this experience.3 many social, cultural, and external factors can lead to increased risks of witnessing domestic abuse in a hispanic household.4 this can include the socioeconomic status of both wife and husband, normalized cultural aspects such as the practice of “machismo,” or recurring substance abuse. socioeconomic status and stress the socioeconomic status of the head of household, especially if it is a male of low socioeconomic level, can lead to an increased risk of domestic abuse.3 this can include measures of income, education, or type of employment. an unemployed father will show a higher propensity for domestic abuse and can result in stress upon their families.5 hispanic households in which the wife and children are economically dependent on an abusive father can present a difficult situation to escape from. the status of residency or citizenship can also influence outcomes. many recently arrived hispanics in the united states show lower levels of acculturation, meaning they are reluctant to adopt the united states’ ways of living. this can bring stress to the family as economic and social marginalization diminishes their initial optimism about moving to the united states. immigrant wives will show great reluctance in reporting cases of domestic abuse out of fear of deportation or from facing language obstacles. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.87 dhr proceedings ǀ http://dhrproceedings.org 34 2023, vol. 2 no. s2 33-39 machismo and modesty the wife and husband in a hispanic family have distinct roles and expected attitudes that influence their behaviors. typically, the father of the family is prone to following the expectations of a “machismo” culture, which can include both positive and negative traits.6 on a positive note, “machismo” encourages the role of a protector and leader of the family, having the father take the responsibility of providing financial strength and support. however, the toxic aspects of “machismo” can force a hispanic father to feel the need to prove his “manhood,” especially in the presence of other men. this can lead to alcohol dependence, abuse geared toward their wife and children, and a lack of sufficient emotional expression.6 as for the mothers in hispanic families, there is a large trend of “modesty” in communication that can diminish their ability to report cases of personal experience with domestic abuse. leading male figures in the hispanic family are usually trusted most with ultimate decision-making. additionally, catholic beliefs and the want to maintain social respectability will make the wife more reluctant to report cases of domestic abuse.6 in the context of recent immigrants, there are many actions towards the preservation of cultural traditions from their home country, also known as, la crianza que nos han dado “the upbringing/legacy that they have given us”.7 this can make it more difficult to acknowledge and escape abusive relationships, particularly when immigrants stray from divorce or separation. impacts of direct and indirect abuse domestic abuse is a behavioral pattern where an individual tends to overpower or control another individual within a relationship with emotionally and physically harmful trends.8 therefore, there can be different types of domestic abuse, indirect and direct. direct domestic abuse includes physical and/or sexual assault, while indirect abuse may include witnessing abuse and/or being neglected.9 individuals who experience any type of abuse, both direct and indirect, are more susceptible to depressive disorders. in a case study looking at the association of gender differences and on-set depression, about 5.7% of the individuals met the criteria for diagnosed depression by the age of 18.10 within this study, 26% experienced direct abuse, and 13.2% experienced indirect abuse. moreover, data analysis have shown that children that live in a household with domestic violence are more susceptible to experiencing physical, sexual, and emotional abuse later on in their life.11 domestic violence can to lead to posttraumatic stress disorder, substance abuse, and more difficulty with relationships.12 in addition, there are some physical impacts on domestic abuse victims, such as having difficulty eating, sleeping, and physical complaints such as headaches. victims also tend to lose interest in social activities, school, and tend to have lower self-esteem. mental health can also be impacted with some reporting anxiety, depression, and posttraumatic stress disorder. this has also caused an influx of domestic violence victims who struggle academically, drop out of school, and/or turn to delinquency. stigmatization & generational trauma stigmatization involves categorizing a trait or characteristic as undesirable and associating negative beliefs or attitudes towards the persons or group that express that trait. the weight of stigma is carried by those experiencing and discussing difficult topics, including domestic violence and mental health. approximately 95% of all residents of the rio grande valley are hispanic and it is known that ethnic minorities have a higher propensity to associate personal stigma with mental health disorders and domestic violence and therefore, may choose not to seek help or treatment.13,14 this is due to the fear of being perceived as being crazy or weak and can lead teenagers to feel incapable of expressing their psychological struggles. other reasons for hesitation to receive treatment in the hispanic community are language barriers, fear of deportation, and financial struggles.15 furthermore, it is shown in studies that hispanic children who come into contact with domestic violence are more likely to endure poor health.16 this kind of domestic abuse can be extremely traumatic and can have long-term effects on a child’s life. some forms of domestic abuse experiences would be witnessing and enduring physical abuse or going through emotional abuse. this could lead to normalizing the idea of domestic abuse and creating an idea that it is acceptable in a family and/or relationship dynamic.17 the hispanic community is one of the most underrepresented cultures when it comes to mental health and receiving help. statistically, approximately 33% of hispanics receive treatment compared to the national average of 43 %.18 this is due to the stigma special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.87 dhr proceedings ǀ http://dhrproceedings.org 35 2023, vol. 2 no. s2 33-39 that hispanics, especially men, have towards mental health. mental health research has shown the general population is less likely to suffer from mental health disorders than victims of domestic abuse.19. psychological, physical, and sexual violence are the three most experienced abuse in teens.12 abuse in adolescents results in cognitive, emotional, biological-based, and behavioral responses. generalized anxiety disorder (gad) is a common mental disorder that can arise after domestic abuse. teens are more prone to show a decline in social activities, self-esteem, and avoidance compared to common gad symptoms. another common mental disorder that results from domestic abuse is depression. it is a mental illness that affects the way we feel negatively and involves feelings of sadness, hopelessness, worthlessness, and emptiness. if left untreated, depression can lead to a high risk of suicidal ideations and substance addictions.20. in hispanic adolescents from 12-17 years old, major depressive order episodes have increased from 12.6% to 15.1% in 2015-2018.15 suicide is the 3rd leading cause of death in the hispanic community between the ages of 10-24 and in men 25-34.21. studies show 15-71% of women have experienced domestic abuse in the form of physical or sexual abuse.22 in the year 2019, it was reported that hispanic teenagers in high school had reported feelings of sadness and hopelessness for more than 1 daily occurrence, which showed drastic increases from the statistics that were previously recorded in 2017.23 post-traumatic stress disorder (ptsd) can also be a result of domestic abuse. the likelihood of ptsd increases after a domestic abuse event, though its effects can be mitigated through seeking emotional support.24 it is reported that 13-50% of youth exposed to domestic abuse qualify for ptsd diagnosis.25 symptoms are normally defined as avoidance, arousal, and reliving the events. symptoms are mostly dependent on the age group of the person. adolescent symptoms include insomnia, aggressive behavior, academic challenges, and the standard response to ptsd. coping mechanisms it is rare to see hispanics admit to their mental health issues, let alone seek help. only 22 percent of hispanic or latin americans have had their mental illness recorded in an institution.21 while the logical move is to find healthy strategies to move forward, many hispanic teens tend to fall into unhealthy coping mechanisms. one of them is to suppress their feelings, especially adolescent males.26 this can be related to the previously mentioned theory of “machismo” that perpetuates the idea that hispanic males must maintain a sense of supremacy, sexism, and restrained emotions.26 if they were to show emotion or speak up about how they feel, they are then considered weak and want to avoid disappointing their families. hispanic female teens may suppress their emotions to avoid being labeled as “dramatic.” another unhealthy coping mechanism is to turn to drugs and alcohol as an escape from their reality.27 the number of reported rates for hispanic or latino americans was 19.4% for illicit drug and 15.7% for substance use disorder.21 even though that’s not the route they should be taking, as they grow up, hiding all the hurt and trauma they experienced can lead to these negative coping mechanisms. fortunately, there are also healthy coping mechanisms that teens can adopt to deal with the abuse they experienced. teens can choose to turn the page on their life and look at it from another perspective and lean toward a more positive recovery.28 one healthy coping mechanism is setting boundaries. as adolescents age, they reach a point where they will no longer endure what they aren’t comfortable with and choose to build new, secure relationships in order to have an adequate healing process. many will also receive the treatment for the mental health disorders that have resulted from the abuse as well as treatment for the abuse they experienced. treatments the effects of domestic abuse on any individual can leave serious mental, physical, and emotional marks. similarly to other conditions, treatment rather than avoidance is recommended for victims to process and handle the impact abuse has had on their life. social workers from mayo clinic suggest the main treatments for victims are therapy, classes, and shelters.29 they explain how to counsel a survivor of domestic abuse by first analyzing the impact the trauma had on the victim and then by providing counseling correlating to the impact. for instance, one of the types of responses a victim may have is the avoidance response. the avoidance response is when the victim dissociates in situations or responds with neutral responses.30 this response can cause a greater cause for concern because it can lead to difficult special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.87 dhr proceedings ǀ http://dhrproceedings.org 36 2023, vol. 2 no. s2 33-39 resolution and post-traumatic stress disorder, ptsd. another common response is dysregulation, which refers to the inability to control emotions and display of a wide range of emotions in short periods of time. therapists or counselors should approach avoidance and dysregulation by slowly developing a tolerance to the abusive memories in order to create a less stressful environment when reminded of them.30 additionally, there are certain classes can help the victim by bringing awareness to the different types of abuse and how to respond in these situations. the classes can also bring light to the structure and cycle of abuse with the intention of preventing future occurrences of abuse. individuals from the national network to end domestic violence, nnedv, have explained that victims of domestic abuse often remain in the same housing where the abuse takes place due to financial and housing situations. thus, shelters often become a safe haven and a necessity to take the victim out of the difficult situation.31 nnedv has recognized this urgency and created a safer community within temporary and transitional housing.31 organizations with similar goals to treat and support victims of domestic abuse have increased awareness throughout the united states. however, the availability and accessibility for hispanics should be examined.27 awareness barriers to accessing resources while awareness campaigns and resources are meant to help the victims abandon their violent homes, there are obstacles that the victims face in order to make use of the resources. for example, the abuser can use threats and create an ultimatum to get victims to be silent about the abuse.1 it is common for abusers to use warnings such as the threat of informing authorities about the victims' undocumented immigration. this discourages domestically abused young hispanics from looking for essential help and resources.1 language barriers to accessing resources while according to pew research center, more than 20% of young hispanics are dominantly spanish speaking.27 this makes it important to bring attention to the language barrier the youth hispanics could and are going through. with the majority of domestic violence awareness campaigns in the united states produced in the english language, they become ineffective for spanish-speaking teens who cannot successfully understand the language.32 furthermore, healthcare providers should communicate with patients in their native language whenever possible.2 while some studies show that healthcare workers may display an unconscious bias when treating non-native english speakers, there are studies that show bias is decreased once the healthcare provider was aware of the bias.32 domestic abuse in hispanics hispanics make up approximately 19% of the population in the united states. of those hispanics, the states with the highest hispanic population are california, texas, florida, new york, and arizona which places 3rd highest in domestic abuse in america.33 in texas, 40% hispanic females and 35% males have experienced some form of domestic abuse including intimate partner violence, rape, or stalking.33 resources there are several resources available to people who are victims of domestic violence and require assistance. the domestic abuse hotline is a 24/7 and multilanguage resource available to those who need help.34 there are also hundreds of shelters, online supporting research, and websites to help support survivors of abuse. the domestic violence evidence project is an online resource center that is designed to help state coalitions, local domestic violence programs, and researchers with the information needed to collaborate and combat domestic violence in their communities.35 the project is focusing on a plan called “the theory of change” that describes the framework for how the work of domestic violence programs help rehabilitate and improve survivors and children of survivors with an 8factor and 3-step plan. the 8 factors are selfsufficiency, hopefulness, social connectedness, safety, having adequate social and economic opportunities, economic stability, enhanced justice, and good physical, emotional & spiritual health. the 3-step plan consists of program activities, program outcomes, and factors predicting well-being.35 additionally, there are also multiple shelters for victims, although there are a higher number of shelters for women rather than men.36 conclusion reporting domestic abuse and violence has always been a struggle for victims. taking a closer look at standards, stigmas, culture, religious beliefs, special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.87 dhr proceedings ǀ http://dhrproceedings.org 37 2023, vol. 2 no. s2 33-39 and fears in the hispanic and latinx communities, we have been able to dissect the struggles hispanics face when it comes to reaching out or seeking help. abuse, whether direct or indirect, experienced by children in hispanic households has both immediate and longterm effects. domestic abuse leads to mental, emotional, and, many times, physical damage that can last a lifetime. physical scars, ptsd, anxiety, depression, and other disorders are at an increased chance of being developed in the victim’s future. the development of abuse on oneself at a young age may cause them to reciprocate the action on others in the future, otherwise known as the cycle of abuse. growing research suggests that exposure to abuse leads to an increased risk of abuse in future relationships as well.37 additionally, language barriers and political fears result in a decrease in reports; however, there are many treatments and coping mechanisms available, both positive and negative. therapy, medication, setting boundaries, have shown encouraging outcomes in victims during and after experiencing abuse. more awareness of the effects of domestic abuse on hispanics in their teens is greatly needed to understand the issues that prevail all around us. addressing these issues will lead to positive changes in the lives of survivors and their families. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. huecker mr, king kc, jordan ga, smock w. domestic violence. 2023 apr 9. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2023 jan–. pmid: 29763066. 2. abuse in the latinx community. the hotline. https://www.thehotline.org/resources/abusein-the-latinx-community/ 3. cummings am, gonzalez-guarda rm, sandoval mf. intimate partner violence among hispanics: a review of the literature. j fam violence. 2013 feb 1;28(2):153-171. doi: 10.1007/s10896-0129478-5. pmid: 23606787; pmcid: pmc3627727. 4. soler h, vinayak p, quadagno d. biosocial aspects of domestic violence. psychoneuroendocrinology. 2000 oct;25(7):721-39. doi: 10.1016/s03064530(00)00022-6. pmid: 10938451. 5. sokoloff nj, pratt c. domestic violence at the margins : readings on race, class, gender, and culture. rutgers university press; 2007. 6. galanti ga. the hispanic family and malefemale relationships: an overview. journal of transcultural nursing. 2003;14(3):180185. doi:https://doi.org/10.1177/1043659603014 003004 7. gonzalez-guarda rm, vasquez ep, urrutia mt, villarruel am, peragallo n. hispanic women’s experiences with substance abuse, intimate partner violence, and risk for hiv. journal of transcultural nursing. 2010;22(1):46-54. doi:https://doi.org/10.1177/1043659610387 079 8. united nations. what is domestic abuse? united nations. published 2020. https://www.un.org/en/coronavirus/what-isdomestic-abuse 9. sousa c, mason wa, herrenkohl ti, prince d, herrenkohl rc, russo mj. direct and indirect effects of child abuse and environmental stress: a life course perspective on adversity and depressive symptoms. american journal of orthopsychiatry. 2018;88(2):180-188. doi:https://doi.org/10.1037/ort0000283 10. dunn ec, gilman se, willett jb, slopen nb, molnar be. the impact of exposure to interpersonal violence on gender differences in adolescent-onset major depression: results from the national comorbidity survey eplication (ncs-r). depression and anxiety. 2012;29(5):392-399. doi:https://doi.org/10.1002/da.21916 11. holt s, buckley h, whelan s. the impact of exposure to domestic violence on children and young people: a review of the literature. child abuse & neglect. 2008;32(8):797-810. doi:https://doi.org/10.1016/j.chiabu.2008.02. 004 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.87 dhr proceedings ǀ http://dhrproceedings.org 38 2023, vol. 2 no. s2 33-39 12. volpe ph.d., b.c.e.t.s. js, american academy of experts in traumatic stress. effects of domestic violence on children and adolescents: an overview. www.aaets.org. published 2020. https://www.aaets.org/traumatic-stresslibrary/effects-of-domestic-violence-onchildren-and-adolescents-an-overview 13. ochoa-perez drm. understanding culture | mental illness in the hispanic community. legacy community health. published may 10, 2016. accessed june 29, 2023. https://www.legacycommunityhealth.org/un derstanding-culture-mental-illness-in-thehispanic-community/#:~:text=hispanic%20 14. defreitas sc, crone t, deleon m, ajayi a. perceived and personal mental health stigma in latino and african american college students. front public health. 2018 feb 26;6:49. doi: 10.3389/fpubh.2018.00049. pmid: 29536000; pmcid: pmc5834514. 15. mental health america. latinx/hispanic communities and mental health. mental health america. published 2022. https://www.mhanational.org/issues/latinxhi spanic-communities-and-mental-health 16. elkington ks, hackler d, mckinnon k, borges c, wright er, wainberg ml. perceived mental illness stigma among youth in psychiatric outpatient treatment. journal of adolescent research. 2011;27(2):290-317. doi:https://doi.org/10.1177/0743558411409 931 17. hispanic tradition of “el machismo” can lead to abuse. ymg. published december 8, 2017. https://www.youthcastmediagroup.org/post/ hispanic-tradition-of-el-machismo-can-leadto-abuse 18. mental health challenges and support: latinx communities. nami california. https://namica.org/mental-health-challengesin-latinocommunities/#:~:text=facts%20about%20 mental%20health%20and%20latino%20c ommunities 19. marketing p. how does domestic abuse affect mental health? bridges dvc. published october 22, 2021. https://www.bridgesdvc.org/how-doesdomestic-abuse-affect-mental-health/ 20. torres f. what is depression? american psychiatric association. published october 2020. https://www.psychiatry.org/patientsfamilies/depression/what-is-depression 21. hispanic/latino. samhsa.gov. published april 8, 2019. https://www.samhsa.gov/behavioral-healthequity/hispanic-latino 22. paddock phd k. mental health disorders linked to domestic violence. www.medicalnewstoday.com. published december 27, 2012. accessed june 29, 2023. https://www.medicalnewstoday.com/articles /254475#6 23. in 2019, 40 percent of latino high schoolers reported feeling sad or hopeless for more than two weeks. hispanic research center. published may 5, 2021. https://www.hispanicresearchcenter.org/hisp -family-facts/in-2019-40-percent-of-latinohigh-schoolers-reported-feeling-sad-orhopeless-for-more-than-two-weeks/ 24. the connection between domestic violence and ptsd. beaufort memorial hospital. published may 11, 2021. https://www.bmhsc.org/blog/the-connectionbetween-domestic-violence-and-ptsd 25. generalized anxiety. mental health foundation. accessed june 29, 2023. https://mentalhealthfoundation.org/healthconditions/anxiety-disorders/generalizedanxiety/?gclid=cj0kcqjw4skbhdqarisaniph0ucacihefr7on2wfvyk9pfbcr8ddkj rynve4yxbpfvwtqrkqitehkaarb2eal w_wcb 26. margolin g, vickerman ka. posttraumatic stress in children and adolescents exposed to family violence: i. overview and issues. professional psychology: research and practice. 2007;38(6):613-619. doi:https://doi.org/10.1037/07357028.38.6.613 27. nuñez a, gonzález p, talavera ga, et al. machismo, marianismo, and negative cognitive-emotional factors: findings from the hispanic community health study/study of latinos sociocultural ancillary study. journal of latina/o psychology. 2016;4(4):202-217. doi:https://doi.org/10.1037/lat0000050 28. schinke sp, moncher ms, palleja j, zayas lh, schilling rf. hispanic youth, substance abuse, and stress: implications for prevention research. the international journal of the addictions. 1988;23(8):809-826. doi:https://doi.org/10.3109/1082608880905 8841 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.87 dhr proceedings ǀ http://dhrproceedings.org 39 2023, vol. 2 no. s2 33-39 29. mcmullen jg. interrupting the intergenerational trauma of family violence – marquette university law school faculty blog. marquette university law school faculty blog. published november 30, 2021. https://law.marquette.edu/facultyblog/2021/ 11/interrupting-the-intergenerationaltrauma-of-family-violence/ 30. barcaglioni j. domestic violence in the hispanic community. safe harbor. published august 31, 2010. https://www.safeharborsc.org/blog/safeharbor-voice/domestic-violence-in-thehispanic-community 31. kippert a. healthy vs. unhealthy coping strategies. domesticshelters.org. published october 14, 2019. https://www.domesticshelters.org/articles/aft er-abuse/healthy-vs-unhealthy-copingstrategies 32. treating survivors of interpersonal violence mayo clinic. www.mayoclinic.org. published february 7, 2020. https://www.mayoclinic.org/medicalprofessionals/trauma/news/treatingsurvivors-of-interpersonal-violence/mac20479434 33. sanderson c. ebscohost login. search.ebscohost.com. published 2008. accessed june 29, 2023. https://search.ebscohost.com/login.aspx?dire ct=true&db=nlebk&an=236338&site=edslive 34. the impact of safe housing on survivors of domestic violence. nnedv. published december 7, 2022. https://nnedv.org/spotlight_on/impact-safehousing-survivors/ 35. florida state university. national prevention toolkit on domestic violence for medical professionals domestic violence for medical professionals.; 2014. https://dvmedtraining.csw.fsu.edu/wpcontent/uploads/2014/01/conditions-andinjuries-2014.pdf 36. domestic violence statistics: a comprehensive investigation. dolan + zimmerman llp. https://www.dolanzimmerman.com/domesti c-violence-statistics/ 37. domestic violence statistics. the hotline. accessed june 29, 2023. https://www.thehotline.org/m/domesticviolence-statistics/ 38. sullivan cm. theory of change how do domestic violence programs promote survivors’ social and emotional wellbeing?; 2012. accessed june 29, 2023. https://www.dvevidenceproject.org/wpcontent/uploads/dvevidence-services-toc2016.pdf 39. mcallen, tx domestic violence help, programs. domesticshelters.org. accessed june 29, 2023. https://www.domesticshelters.org/help/tx/mc allen 40. russell d, springer kw, greenfield ea. witnessing domestic abuse in childhood as an independent risk factor for depressive symptoms in young adulthood. child abuse & neglect. 2010;34(6):448-453. doi:https://doi.org/10.1016/j.chiabu.2009.10. 004 special edition: junior clinical research (2022), vol. 2 no. s2 https://doi.org/10.47488/dhrp.v2is2.59 dhr proceedings ǀ http://dhrproceedings.org 78 2022, vol. 2 no. s2 78-85 commentary cervical cancer risks and outcomes in hispanic women adrian alberto salinas1,2, daniella barrera1,2, mia brizuela1,3, andrea sophia cordova1,3, natalia palau1,3, alysa gonzalez1,2, juan correa jr.1,3, esmeralda rios1,2, rosa villarreal1,3 12nd annual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research & development 2edinburg high school, edinburg, tx 3lyndon b johnson, laredo, tx all correspondence should be addressed to program director, 2nd annual junior clinical research internship program, dhr health institute for research & development, 5323 s mccoll road, edinburg texas, 78539 received 07/01/2022 accepted for publication 08/05/2022 published 08/05/2022 keywords: cervical cancer; hpv-16; hpv-18 introduction cervical cancer is a worldwide threat affecting women, particularly in impoverished communities that lack adequate healthcare. cervical cancer is a malignant tumor of the lower part of the uterus. cervical cancer affects women throughout the world from all walks of life. although it affects all races, there are disparities among ethnic groups depending on geographic location. certain geographic locations such as the rio grande valley have higher incidence of cervical cancer. the rio grande valley has a large hispanic population and many of these women do not seek medical care which could prevent or improve cervical cancer diagnosis (1). in 2018 there were 570,000 cases of cervical cancer and 311,000 deaths from it around the world (2). cervical cancer was the fourth most common disease in women. china and india together contributed more than a third of the global cervical burden, with 106,000 cases and 48,000 deaths in china, and in india 97,000 cases and 60,000 deaths (2). cervical cancer ranked in the top three cancers affecting women younger than 45 years in 146 (79%) of 185 countries assessed (2). in texas, it was recorded by the texas health and human services in 2019 that there were over 1,395 women affected by cervical cancer and an estimated 447 would die from the disease (2). risks human papillomavirus human papillomavirus also known as hpv is a non-enveloped, double-stranded, circular dna virus that has been proven to be a leading factor in the development of cervical cancer in women (3). hpv has over 100 subtypes identified, and from those 100 there are many subtypes that are specifically associated with the development of cervical cancer some of them being subtypes 16, 18, 31, 33, 35, 45, 52, and 58 (4) for example, hpv 16 has been shown to affect the genomes of the host (13). even though hpv is not genetically inherited, recent studies have discovered the variant to be transmitted naturally. the variant has been discovered in european-asians, europeans, and africans (5). hpv also contains viral salinas, et al. cervical cancer risks https://doi.org/10.47488/dhrp.v2is2.59 dhr proceedings ǀ http://dhrproceedings.org 79 2022, vol. 2 no. s2 78-85 proteins that cause infection and ultimately progress into cancer some being e1-e7 and l1-l2 which again are essential for a viral propagation (3). the virus for the most part is acquired through sexual activity and develops into the body when it enters the epithelium through disruptions of the skin/mucosa and starts infecting the basal stem cells (see figure 1) (4). but this viral dna doesn’t instantly merge into a person’s genome, it remains as an independent episome for a period before that. and even though hpv is a leading factor associated with cervical cancer. it alone cannot cause cancer and there are factors that trigger it to happen such as smoking, pregnancy/childbirth, and the use of oral contraception (4). to prevent certain cancerous lesions and subtypes there is a vaccine that has been shown to be helpful when it comes to the prevention of cancers that hpv can cause, and it is said to be most effective when given during the ages of 9-12 or before teens initiate in sexual activity (4). prevention of contracting hpv may also include abstinence practicing safe sex. figure 1 smoking smoking does not only cause long-term effects with your lungs, but it has more recently been proven to be linked with hpv and cervical cancer. in a study published in the journal of epidemiology and public health, researchers found that women who were exposed to second-hand smoke had a 73% increase in risk for developing cervical cancer, especially if they were already exposed to hpv (6). researchers also stated that women that were exposed have a 12.57% more likely chance of having cervical cancer (6). tobacco products affect the body's immune system, and this makes it harder for women who smoke to fight off infections and viruses that they may contract into their bodies (6). therefore, avid smokers or women with constant exposure to second-hand smoke who experience frequent hpv infections may be more likely to develop a cancer like cervical cancer over time. use of oral contraceptives oral contraceptives (ocs) are currently prescribed as an effective way of preventing unwanted pregnancies. however, similar to other medications, ocs come with a plethora of unwanted side-effects. some of these side effects could lead to cervical cancer. the specific ocs associated with these cervical cancers are implants, vaginal rings, and other progesterone contraceptives (7). according to research on estrogen-progestogen and progestogenonly contraceptives, synthetic steroids stimulate receptors all over the body and may lead to development of cancer. these receptors are very prominent in reproductive tissues. however, immune cells and other tissues are also affected by these hyperactive receptors. the longer the ocs are used, the higher the risk of developing cervical cancer. moreover, a study conducted over a 10-year span concluded that women who use oc’s are at a 95% increase of cervical cancer. it was discovered that oc’s not only higher the risk of cervical cancer but also influence its formation (8). diet although there is an insignificant amount of information regarding diet and nutrition in relation to hpv and cervical cancer, a western diet is considered a high-risk for cervical cancer. in a study done by the university of catania where they monitored the dietary patterns, women following a western diet were considered to be high-risk (9). research indicated women consuming a “western” diet which consisted of a higher intake of red and processed meats and foods such as chips and other snacks were generally associated with a higher risk of developing hpv and other hpv-related cervical lesions (9). alternatively, women that had a more “prudent” diet that consisted of a higher intake of raw vegetables, legumes, and vegetable soups were less likely to be at risk of developing hpv and other infections (see figure 2) (9). dietary antioxidants such as vitamin d and carotenes have also been proven to help fight against/neutralize harmful ros that may be in a woman's body or on its own (10). salinas, et al. cervical cancer risks https://doi.org/10.47488/dhrp.v2is2.59 dhr proceedings ǀ http://dhrproceedings.org 80 2022, vol. 2 no. s2 78-85 figure 2. foods that positively (green) and negatively (red) characterize dietary patterns. pca1: western diet & pca2: prudent diet. genetics researchers have discovered through several research studies that some genetic aspects may increase the probability of developing cervical cancer. it is considered that 36% of cervical cancer cases may be linked to genetics (11). decir 1 is a gene that has been linked to an increased risk of cervical cancer as well as other types of cancer. dicer1 is a rare genetic mutation that makes an individual more prone to the development and growth of tumors. these tumors have been associated with cervical cancer (12). dicer1 syndrome typically affects young females with cervical cancer patients who are in their twenties or younger (13). dicer1 syndrome is not the only genetic link between cervical cancer and women. cervical cancer screening screening is essential, particularly for younger females to detect cervical cancer. ages starting from 21 to as much as 65 years old are at critical risk to receive cervical cancer. papanicolaou screenings is a procedure where tissue is removed from the surface and around the cervix to check for malignant cells. these tests are recommended for females aged 21–29-year-old at least every three years (14). using human papillomavirus dna test and pap smear are tests recommended for early detection and risks of cervical cancer (15). ethnic differences and disparities in hispanic women through research it was found that women from both hispanic and african american populations run a higher risk of developing cervical cancer. hispanic women are nearly twice as likely to be diagnosed with cervical cancer as opposed to other populations and furthermore african american women are more likely to die from this disease (15, 16). access to testing such the pap-smear test is difficult for women of these populations due to lack of access to health care, education, and awareness campaigns (14). according to research, ethnicity is a major factor and a disparity as well to access to health care, therefore the lack of screening tools to detect early signs of cervical cancer is a huge problem in our country. all of the above may contribute to the increase in cervical cancer cases in these populations (14). another very important factor as far as ethnic differences and disparities is the issue of health literacy and why it is important for health care facilitators to educate populations of hispanic women. research has found that health illiteracy and cervical cancer screening among mexican american women needs to be addressed and is essential to improving outcomes (17). culture in addition to the high prevalence of cervical cancer in hispanic women, culture and social factors contribute to the lack of understanding of the disease. due to the lack of understanding of the disease, families and caretakers are unable to communicate and provide awareness about the importance of getting salinas, et al. cervical cancer risks https://doi.org/10.47488/dhrp.v2is2.59 dhr proceedings ǀ http://dhrproceedings.org 81 2022, vol. 2 no. s2 78-85 tested (18). the latina women’s stigma of privacy especially when it comes to certain healthcare practices is a big factor, therefore putting them at risk (18). hispanic cultural beliefs such as stigma surrounding sensitive health topics, alternative remedies promoted and consumed, and the gender of the physician may often lead to negative outcomes because they are not well informed of the awareness and dangers of cervical cancer. lack of education, healthcare services, and additional resources may possibly contribute to negative outcomes for these women (18). stages, signs, and symptoms of cervical cancer progressing stages of cervical cancer through research, it has been discovered that cervical cancer is an abnormal growth of malignant cells located in the cervix and metastasizes as the tumor grows (19). cervical cancer has four stages, each containing sub-stages (20). stages are organized by severity, determined by the depth of the tumor and whether it has spread (21). stage i in the initial stage i, the cancer or tumor is limited to the cervix (21). as previously mentioned, cancer has sub-stages known as ia1, ia2, ib1, ib2, and ib3 (21). the difference in sub-stages between ia1 and ia2 is that the tumors in ia1 are less than or equal to 3 mm (⅛ inches) deep (21). whereas in ia2, the tumor’s depth is between 3 mm and 5 mm (⅕ inches). from sub-stage ib1, the tumor is deeper than 5 mm but no more than 2 cm (⅘ inches). the tumor’s size in ib2 is between 2 cm4cm. stage ib3 cancer is at least 4 cm in size but is only limited to the cervix (21). stage ii stage ii consists of three sub-stages, iia1, iia2, and iib1 (figure 3). cancer in sub-stages iia1 and iia2 spread beyond the cervix and the uterus, yet it has not reached the parametrium, which is a connective tissue to the pelvis, surrounding the uterus (22). the size of the tumor is no larger than 4 cm (about 1 3/5 inches) in iia1, and in iia2, the cancer is 4 cm or larger. unlike iia1 and iia2, cancer in the iib1 phase has developed in the tissue of the cervix, the parametria, and beyond the cervix and uterus. stage iii stage iii cancer has metastasized to the lower area of the vagina and/or walls of the pelvis and has three sub-levels known as iiia, iiib, and iiic (figure 3) (21). cancer in iiia has invaded the lower part of the vagina. on the contrary, the tumor in iiib can spread to the walls of the pelvis. in this stage, not only can it block one or both of the ureters, but it could also affect the kidneys and cause hydronephrosis (21). hydronephrosis is a condition where there is an abnormal enlargement of the kidneys, caused by blockage of the ureters or urine leaving the bladder (23). the tumor in iiic, regardless of the size, can metastasize to the pelvic lymph nodes (iiic1) or paraaortic lymph nodes (iiic2). stage iv ultimately, the last phase of the cancer is stage iv (21). the severity of cancer has grown and affected other organs, such as the bladder, rectum, and depending on the extremity, the lungs, or bones. sublevel iva focuses on cancer growing out of the pelvis, affecting the bladder, and/or rectum. ivb, the other phase of stage iv, is when the tumor has advanced to other distant organs outside of the pelvis area, such as bones, lymph nodes, and lungs (figure 3) (24). figure 3 staging in cervical cancer salinas, et al. cervical cancer risks https://doi.org/10.47488/dhrp.v2is2.59 dhr proceedings ǀ http://dhrproceedings.org 82 2022, vol. 2 no. s2 78-85 signs and symptoms regarding the signs and symptoms of cervical cancer, patients undergo specific characteristics as cancer progresses. some of these signs and symptoms appear early on in certain cancers, yet in cervical cancer, they do not appear till later as the cancer advances and/or is hard to detect (20). within stage i, women may find signs of watery or vaginal discharge that is dense and may have a foul odor. patients can have vaginal bleeding after intercourse, between menstrual cycles, or after menopause, and their menstrual periods may be heavier and last longer than usual (20). these signs are mainly considered within the first stage of cervical cancer. however, as the cancer advances and worsens throughout the body, such as stages ii-iv, patients may experience pelvic/abdominal pain, diarrhea or pain and rectal bleeding, fatigue, rapid weight loss of more than 10 lbs., loss of appetite, backaches or swelling in the legs, painful/difficult urination with blood in the urine, and an overall sense of feeling ill (20). trends of cervical cancer trends in incidence cervical cancer is one of the most common cancers in females worldwide. in the united states, its incidence and mortality rate has been declining due to the wide scale screenings, pap tests, and/or pap smear tests (25). the screening procedure can find cervical cancer early. most patients are diagnosed between the ages of 35 and 44 and the average age at diagnosis is 50 years old (26). patients diagnosed with cervical cancer are also likely to have hpv and most patients have a history of smoking cigarettes. researchers for cervical cancer once stated that cervical cancer was one of the most common cancerous deaths for women in the united states. the cervical cancer rate has dropped significantly with women now taking pap tests/pap smear tests (26). people younger than 20 years old rarely develop cervical cancer; however, the risk does go up for women in their mid 30s. many older women do not realize that the risk of developing cervical cancer is still going up as they age (26). trends in hpv every year, about 19,400 women may experience cancers caused by hpv including cervical cancer. in recent years, the hpv test has been approved as another screening test for cervical cancer because almost all cervical cancer patients are caused by hpv. many of the patients that found out they had hpv was because of their symptoms, for example, pelvic pain during intercourse, vaginal bleedings between periods or after menopause, and watery, blooding vaginal discharge (27). hpv is the most common infection of the reproductive tract this can be due to the fact that this virus can be transmitted during intercourse. some cervical cancers come from an hpv infection of gland cells in the cervix and are called adenocarcinomas. most women find out they have hpv when they get an abnormal pap test result. if present, the test can determine whether the hpv is a lowor a high-risk type. studies show that even though there is no treatment for the virus itself, there are treatments for the health problems that hpv causes, for instance, cervical precancer treatment is available. women who get routine pap tests and follow-ups can identify problems before the cancer develops. additionally, the hpv vaccine can be administered starting at the age 9, through 26 years (28). history of cigarette usage women who smoke are about twice as likely as those who do not smoke to be diagnosed with cervical cancer. when someone smokes, they and people around them are exposed to many cancercausing chemicals that affect organs other than the lungs. these dangerous substances can be absorbed through the lungs and carried throughout the bloodstream and go around the body. tobacco byproducts have been found in the cervical mucus of women who smoke and who have been diagnosed with cervical cancer (29). studies show that these substances can damage the dna of cervix cells and may contribute to the development of cervical cancer (30). it has also been studied that smoking can weaken your immune system which also makes you more likely to be affected by hpv(31). patients that are diagnosed with cervical cancer tend to have a history of smoking. smoking has been known to impact the immune system cells that are important in fighting the hpv virus, allowing the virus to promote precancerous lesions and cancer of the cervix and genital areas (32). prevention and treatment cervical cancer is a very common cancer in women, especially in latin women, however there are salinas, et al. cervical cancer risks https://doi.org/10.47488/dhrp.v2is2.59 dhr proceedings ǀ http://dhrproceedings.org 83 2022, vol. 2 no. s2 78-85 various ways to treat this cancer. in fact, cervical cancer rates for latino women are 44% higher than any other race (15). one reason for the higher incidence of cervical cancer is that latinas are less likely to get regular pap tests due to lack of financial resources (15). since they cannot afford to attend the doctor regularly and be screened for cervical cancer, the cancer can grow undetected and cause damage, which can be fatal. spreading awareness can increase screening and mortality can be reduced. early education is also important. parents should talk with their children about these topics regarding their reproductive system. since it may be difficult for parents to broach the topic of the reproductive system, there should be programs at school to teach students more about their bodies. after students gain this knowledge, they can help educate others which will spread further awareness and maybe in the future, the rates of cervical cancer in latina women may go down. the most accessible way women can prevent cervical cancer is by taking the hpv vaccine. it is usually given to children between the ages of 11 to 12 years old (33). if women still develop cervical cancer, there are surgical options available such as cervicectomy surgery or radical trachelectomy surgery. the difference between these two options is very crucial. radical trachelectomy allows the patient to still be able to reproduce by removing only the cervix unlike in the cervical surgery where both the cervix and the uterus are removed (34). conclusion the mortality and morbidity of cervical cancer may not be a preventable disease in areas where healthcare is not accessible. however, pap tests, which are a screening tool for cervical cancer, can be used for early detection. cervical cancer is prevalent in women, but health literacy and awareness may be some factors that also need to be addressed in communities where it is not as accessible, as is the case in south texas. in conclusion, cervical cancer has various treatments but many people, especially in cities of south texas are not fully educated to understand the repercussions of cancer as well as the stigma that comes with the culture. more studies for how to deliver education to communities that lack the knowledge of how cervical cancer can be prevented, access to healthcare and disparities for the low-income families are needed. acknowledgments dr. monica betancourt-garcia, md, scientific director; melissa eddie, ms, program manager; xochitl lopez, bs, program coordinator funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected and region one esc paths references 1. kish, j. k., rolin, a. i., zou, z., cucinelli, j. e., tatalovich, z., saraiya, m., & altekruse, s. f. (2016). prioritizing us cervical cancer prevention with results from a geospatial model. journal of global oncology, 2(5), 275–283. https://doi.org/10.1200/jgo.2015.001677 2. marc arbyn, elisabete weiderpass, laia bruni, silvia de sanjosé, mona saraiya, jacques ferlay, freddie bray, december 4th , 2020, estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis , elsevier ltd https://doi.org/10.1016/s2214109x(19)30482-6 3. shandra devi balasubramaniam, venugopal balakrishnan, chern ein oon, and gurjeet kaur,2019 july 17th, key molecular events in cervical cancer development,https://www.ncbi.nlm.nih.gov/ pmc/articles/pmc6681523/ 4. lynette luria; gabriella cardozafavarato,january 24 ,2022,human papillomavirus,statpearls publishing llc,https://www.ncbi.nlm.nih.gov/books/n bk448132/ 5. cornet, i., gheit, t., franceschi, s., vignat, j., burk, r. d., sylla, b. s., tommasino, m., clifford, g. m., & iarc hpv variant study group (2012). human papillomavirus type 16 genetic variants: phylogeny and classification based on e6 and lcr. journal of virology, 86(12), 6855–6861. https://doi.org/10.1128/jvi.00483-12 6. roiela arfailasufandi, ambar mudigdo, aris sudiyanto, 2019,the effect of obesity, oral contraceptive and passive smoking on the risk of cervical cancer, https://doi.org/10.1200/jgo.2015.001677 https://doi.org/10.1016/s2214-109x(19)30482-6 https://doi.org/10.1016/s2214-109x(19)30482-6 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6681523/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6681523/ https://www.ncbi.nlm.nih.gov/books/nbk448132/ https://www.ncbi.nlm.nih.gov/books/nbk448132/ https://doi.org/10.1128/jvi.00483-12 salinas, et al. cervical cancer risks https://doi.org/10.47488/dhrp.v2is2.59 dhr proceedings ǀ http://dhrproceedings.org 84 2022, vol. 2 no. s2 78-85 https://jepublichealth.com/index.php?journal =jepublichealth&page=article&op=view&pa th%5b%5d=141 7. williams, w. v., mitchell, l. a., carlson, s. k., & raviele, k. m. (2018). association of combined estrogen-progestogen and progestogen-only contraceptives with the development of cancer. the linacre quarterly, 85(4), 412–452. https://doi.org/10.1177/0024363918811637 8. loopik, d. l., inthout, j., melchers, w., massuger, l., bekkers, r., & siebers, a. g. (2020). oral contraceptive and intrauterine device use and the risk of cervical intraepithelial neoplasia grade iii or worse: a population-based study. european journal of cancer (oxford, england : 1990), 124, 102– 109. https://doi.org/10.1016/j.ejca.2019.10.009 9. barchitta, m., maugeri, a., quattrocchi, a., agrifoglio, o., scalisi, a., &amp; agodi, a. (2018, april 11). the association of dietary patterns with high-risk human papillomavirus infection and cervical cancer: a cross-sectional study in italy. mdpi. retrieved june 29, 2022, from https://www.mdpi.com/20726643/10/4/469/htm 10. michał ciebiera, sahar esfandyari,hiba siblini,lillian prince,hoda elkafas,cezary wojtyła, ayman al-hendy, and mohamed ali, april 2nd ,2021,nutrition in gynecological diseases: current perspectives,multidisciplinary digital publishing institute https://www.ncbi.nlm.nih.gov/pmc/articles/p mc8065992/#b188-nutrients-13-01178 11. bowden, s. j., bodinier, b., kalliala, i., zuber, v., vuckovic, d., doulgeraki, t., whitaker, m. d., wielscher, m., cartwright, r., tsilidis, k. k., bennett, p., jarvelin, m. r., flanagan, j. m., chadeau-hyam, m., kyrgiou, m., & finngen consortium (2021). genetic variation in cervical preinvasive and invasive disease: a genome-wide association study. the lancet. oncology, 22(4), 548– 557. https://doi.org/10.1016/s14702045(21)00028-0 12. caroleo, a. m., de ioris, m. a., boccuto, l., alessi, i., del baldo, g., cacchione, a., agolini, e., rinelli, m., serra, a., carai, a., & mastronuzzi, a. (2021). dicer1 syndrome and cancer predisposition: from a rare pediatric tumor to lifetime risk. frontiers in oncology, 10, 614541. https://doi.org/10.3389/fonc.2020.614541 13. li, rose fanghong md*; gupta, mamta mbbs*; mccluggage, w. glenn frcpath†; ronnett, brigitte m. md*,‡ embryonal rhabdomyosarcoma (botryoid type) of the uterine corpus and cervix in adult women, the american journal of surgical pathology: march 2013 volume 37 issue 3 p 344355 14. balasubramaniam, s. d., balakrishnan, v., oon, c. e., & kaur, g. (2019). key molecular events in cervical cancer development. medicina (kaunas, lithuania), 55(7), 384. https://doi.org/10.3390/medicina55070384 15. despres, c., (2018). the crisis of cervical cancer among latinas. salud america! https://salud-america.org/crisis-cervicalcancer-among-latinas/ 16. gelman, a., miller, e., schwarz, e. b., akers, a. y., jeong, k., & borrero, s. (2013). racial disparities in human papillomavirus vaccination: does access matter?. the journal of adolescent health : official publication of the society for adolescent medicine, 53(6), 756–762. https://doi.org/10.1016/j.jadohealth.2013.07. 002 17. williams-brennan, l., gastaldo, d., cole, d. c., & paszat, l. (2012). social determinants of health associated with cervical cancer screening among women living in developing countries: a scoping review. archives of gynecology and obstetrics, 286(6), 1487– 1505. https://doi.org/10.1007/s00404-0122575-0 https://pubmed.ncbi.nlm.nih.gov/23011733/ 18. flores, b., acton, g., arevalo-flechas, l., gill, s., mackert, michael. (2019). health literacy and cervical cancer screening among mexican-american women. hlrp: health literacy research and practice. 3. e1e8. 10.3928/24748307-20181127-01. https://www.researchgate.net/publication/33 0454096_health_literacy_and_cervical_ca ncer_screening_among_mexicanamerican_women/citation/download johnson, m., & farquharson, h. (2019). hispanic culture and healthcare in the united states: one person’s perspective. journal of nursing research and practice. 03. 10.37532/jnrp.2019.3(4).1-2. https://www.researchgate.net/publication/33 9235483_hispanic_culture_and_healthcare_ https://jepublichealth.com/index.php?journal=jepublichealth&page=article&op=view&path%5b%5d=141 https://jepublichealth.com/index.php?journal=jepublichealth&page=article&op=view&path%5b%5d=141 https://jepublichealth.com/index.php?journal=jepublichealth&page=article&op=view&path%5b%5d=141 https://doi.org/10.1177/0024363918811637 https://doi.org/10.1016/j.ejca.2019.10.009 https://www.mdpi.com/2072-6643/10/4/469/htm https://www.mdpi.com/2072-6643/10/4/469/htm https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8065992/#b188-nutrients-13-01178 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8065992/#b188-nutrients-13-01178 https://doi.org/10.1016/s1470-2045(21)00028-0 https://doi.org/10.1016/s1470-2045(21)00028-0 https://doi.org/10.3389/fonc.2020.614541 https://doi.org/10.3390/medicina55070384 https://salud-america.org/crisis-cervical-cancer-among-latinas https://salud-america.org/crisis-cervical-cancer-among-latinas https://doi.org/10.1016/j.jadohealth.2013.07.002 https://doi.org/10.1016/j.jadohealth.2013.07.002 https://doi.org/10.1007/s00404-012-2575-0 https://doi.org/10.1007/s00404-012-2575-0 https://pubmed.ncbi.nlm.nih.gov/23011733/ https://www.researchgate.net/publication/330454096_health_literacy_and_cervical_cancer_screening_among_mexican-american_women/citation/download https://www.researchgate.net/publication/330454096_health_literacy_and_cervical_cancer_screening_among_mexican-american_women/citation/download https://www.researchgate.net/publication/330454096_health_literacy_and_cervical_cancer_screening_among_mexican-american_women/citation/download https://www.researchgate.net/publication/330454096_health_literacy_and_cervical_cancer_screening_among_mexican-american_women/citation/download https://www.researchgate.net/publication/339235483_hispanic_culture_and_healthcare_%0cin_the_united_states_one_person's_perspective/citation/download https://www.researchgate.net/publication/339235483_hispanic_culture_and_healthcare_%0cin_the_united_states_one_person's_perspective/citation/download salinas, et al. cervical cancer risks https://doi.org/10.47488/dhrp.v2is2.59 dhr proceedings ǀ http://dhrproceedings.org 85 2022, vol. 2 no. s2 78-85 in_the_united_states_one_person's_perspe ctive/citation/download 20. centers for disease control and prevention. (2021, december 14) basic information about cervical cancer. retrieved from https://www.cdc.gov/cancer/cervical/basic_i nfo/index.htm 21. cleveland clinic. (2022, february 17) cervical cancer. retrieved from https://my.clevelandclinic.org/health/disease s/12216-cervical-cancer 22. american cancer society. (2020, january 3) cervical cancer stages: how to stage cervical cancer. retrieved from https://www.cancer.org/cancer/cervicalcancer/detection-diagnosisstaging/staged.html 23. national cancer institute, (n.d.) nci dictionary on cancer terms. retrieved from https://www.cancer.gov/publications/diction aries/cancer-terms/def/parametrium 24. national cancer institute, (n.d.) nci dictionary on cancer terms. retrieved from https://www.cancer.gov/publications/diction aries/cancer-terms/def/hydronephrosis 25. hasan, doaa & enaba, manal & el-rahman, hossam & el-shazely, shrin. (2015). apparent diffusion coefficient value in evaluating types, stages and histologic grading of cancer cervix. the egyptian journal of radiology and nuclear medicine. 20. 10.1016/j.ejrnm.2015.04.006. 26. [buskwofie, a., david-west, g., & clare, c. a. (2020). a review of cervical cancer: incidence and disparities. journal of the national medical association, 112(2), 229– 232. https://doi.org/10.1016/j.jnma.2020.03.002 27. key statistics for cervical cancer (2022 ,january12) https://www.cancer.org/cancer/cervicalcancer/about/keystatistics.html#:~:text=cervical%20cancer% 20is%20most%20frequently,age%20at%20d iagnosis%20being%2050%20 ]. 28. cervical cancer (symptoms). https://www.mayoclinic.org/diseasesconditions/cervical-cancer/symptomscauses/syc-20352501 29. cervical cancer screening and prevention (2021, july13 https://medlineplus.gov/ency/patientinstructi ons/000419.htm ]. 30. prokopczyk, b., cox, j. e., hoffmann, d., & waggoner, s. e. (1997). identification of tobacco-specific carcinogen in the cervical mucus of smokers and nonsmokers. journal of the national cancer institute, 89(12), 868– 873. https://doi.org/10.1093/jnci/89.12.868 31. risk factors of cervical cancer, 2020, january 3 https://www.cancer.org/cancer/cervicalcancer/causes-risks-prevention/riskfactors.html#:~:text=women%20who%20s moke%20are%20about,the%20development %20of%20cervical%20cancer 32. smoking and cervical cancer(2010,april)https://www.urmc.roches ter.edu/medialibraries/urmcmedia/obgyn/midwifery/resources/documents/smokin g_and_cervical_cancer.pdf]. 33. the hpv vaccine: why parents really choose to refuse. johns hopkins medicine newsroom. (2018, october 24). retrieved june 30, 2022, from https://www.hopkinsmedicine.org/news/new sroom/news-releases/the-hpv-vaccine-whyparents-really-choose-to-refuse 34. segarra-vidal, b., persson, j., & falconer, h. (2021). radical trachelectomy. international journal of gynecological cancer: official journal of the international gynecological cancer society, 31(7), 1068–1074. https://doi.org/10.1136/ijgc-2020-001782 https://www.researchgate.net/publication/339235483_hispanic_culture_and_healthcare_%0cin_the_united_states_one_person's_perspective/citation/download https://www.researchgate.net/publication/339235483_hispanic_culture_and_healthcare_%0cin_the_united_states_one_person's_perspective/citation/download https://www.cdc.gov/cancer/cervical/basic_info/index.htm https://www.cdc.gov/cancer/cervical/basic_info/index.htm https://my.clevelandclinic.org/health/diseases/12216-cervical-cancer https://my.clevelandclinic.org/health/diseases/12216-cervical-cancer https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/staged.html https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/staged.html https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/staged.html https://www.cancer.gov/publications/dictionaries/cancer-terms/def/parametrium https://www.cancer.gov/publications/dictionaries/cancer-terms/def/parametrium https://www.cancer.gov/publications/dictionaries/cancer-terms/def/hydronephrosis https://www.cancer.gov/publications/dictionaries/cancer-terms/def/hydronephrosis https://doi.org/10.1016/j.jnma.2020.03.002 https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html#:~:text=cervical%20cancer%20is%20most%20frequently,age%20at%20diagnosis%20being%2050%20 https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html#:~:text=cervical%20cancer%20is%20most%20frequently,age%20at%20diagnosis%20being%2050%20 https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html#:~:text=cervical%20cancer%20is%20most%20frequently,age%20at%20diagnosis%20being%2050%20 https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html#:~:text=cervical%20cancer%20is%20most%20frequently,age%20at%20diagnosis%20being%2050%20 https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html#:~:text=cervical%20cancer%20is%20most%20frequently,age%20at%20diagnosis%20being%2050%20 https://www.mayoclinic.org/diseases-conditions/cervical-cancer/symptoms-causes/syc-20352501 https://www.mayoclinic.org/diseases-conditions/cervical-cancer/symptoms-causes/syc-20352501 https://www.mayoclinic.org/diseases-conditions/cervical-cancer/symptoms-causes/syc-20352501 https://medlineplus.gov/ency/patientinstructions/000419.htm https://medlineplus.gov/ency/patientinstructions/000419.htm https://doi.org/10.1093/jnci/89.12.868 https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html#:~:text= https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html#:~:text= https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html#:~:text= https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html#:~:text=women%20who%20smoke%20are%20about,the%20development%20of%20cervical%20cancer https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html#:~:text=women%20who%20smoke%20are%20about,the%20development%20of%20cervical%20cancer https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html#:~:text=women%20who%20smoke%20are%20about,the%20development%20of%20cervical%20cancer https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html#:~:text=women%20who%20smoke%20are%20about,the%20development%20of%20cervical%20cancer https://www.urmc.rochester.edu/medialibraries/urmcmedia/ob-gyn/midwifery/resources/documents/smoking_and_cervical_cancer.pdf https://www.urmc.rochester.edu/medialibraries/urmcmedia/ob-gyn/midwifery/resources/documents/smoking_and_cervical_cancer.pdf https://www.urmc.rochester.edu/medialibraries/urmcmedia/ob-gyn/midwifery/resources/documents/smoking_and_cervical_cancer.pdf https://www.urmc.rochester.edu/medialibraries/urmcmedia/ob-gyn/midwifery/resources/documents/smoking_and_cervical_cancer.pdf https://www.hopkinsmedicine.org/news/newsroom/news-releases/the-hpv-vaccine-why-parents-really-choose-to-refuse https://www.hopkinsmedicine.org/news/newsroom/news-releases/the-hpv-vaccine-why-parents-really-choose-to-refuse https://www.hopkinsmedicine.org/news/newsroom/news-releases/the-hpv-vaccine-why-parents-really-choose-to-refuse https://doi.org/10.1136/ijgc-2020-001782 adrian alberto salinas1,2, daniella barrera1,2, mia brizuela1,3, andrea sophia cordova1,3, natalia palau1,3, alysa gonzalez1,2, juan correa jr.1,3, esmeralda rios1,2, rosa villarreal1,3 introduction special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 1 2023, vol. 3 no. s1 1--10 commentary ai-powered precision oncology: computational insights redefining therapeutic landscapes adhira tippur1 1mathematics and science academy at the university of texas rio grande valley, edinburg, tx received: august 15, 2023 accepted for publication: october 25, 2023 published: october 27, 2023 introduction cancer is one of the world’s leading causes of deaths creating a worldwide health challenge (1). the number of cancer deaths is rising, presenting a formidable and concerning challenge in healthcare. cancer involves the uncontrolled proliferation of abnormal cells, disrupting the body's normal growth regulation. moreover, the immune system, which typically acts as a defense against such abnormalities, may falter, leading to the evasion of cancerous cells from detection and elimination (1). among the various types of cancer, the most frequently diagnosed ones include lung cancer (accounting for 12.7% of cases), breast cancer (10.9% of cases), colorectal cancer (9.7% of cases), and gastric cancer (7.81% of cases) (2). over the years from 1991 to 2018, cancer-related mortality has shown a steady decline of 31%, primarily attributed to advancements in early detection, treatment, and reductions in smoking (3). despite this positive trend, cancer continues to be a significant contributor to global mortality rates. anticipated data for the year 2023 reveals a projected 1,958,310 new cancer cases, accompanied by 609,820 cancer-related deaths across the united states (4). during the period from 2014 to 2019, prostate cancer experienced a concerning annual increase of 3% in incidence, leading to the diagnosis of approximately 99,000 additional cases. conversely, other cancer incidence trends demonstrated a more favorable outlook in men when compared to women, further emphasizing the importance of ongoing research and targeted interventions to address these disparities. additionally, recent findings highlight a concerning increase in early onset cancer incidence among younger individuals, while overall rates remain stable or decline; unfortunately, younger cancer patients are often diagnosed at more advanced stages, significantly impacting their chances of successful treatment and cure (5). despite significant advancements in cancer research and treatment, the disease remains challenging to cure completely. consequently, the pressing need for alternative approaches becomes paramount, especially to offer effective solutions for high-risk patients. therefore, cancer research will undoubtedly remain at the forefront in the years to come, driven by a resolute commitment to saving lives and pioneering groundbreaking advancements. artificial intelligence (ai) is a dynamic and evolving field of research that involves the application of computer systems to replicate and simulate human intelligence (6). with the aid of advanced algorithms, ai strives to emulate cognitive functions, enabling computers to analyze data, recognize patterns, make decisions, and learn from experiences, much like the human mind. machine learning and deep learning are the major constituents of artificial intelligence (figure 1). machine learning represents a fascinating scientific discipline centered around the art of computer systems learning from data (7). it emerges from the confluence of statistics, which delves into deciphering relationships from data, and computer science, with its core focus on devising efficient computing algorithms. the seamless integration of mathematics and computer science in machine learning emerges as a result of the complex computational intricacies required to construct statistical models from extensive special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 2 2023, vol. 3 no. s1 1--10 datasets, which can consist of billions or even trillions of data points (8). deep learning utilizes multi-layered computational models to learn data representations with multiple levels of abstraction (9). by employing the backpropagation algorithm, machines adjust their internal parameters, computing representations in each layer based on the previous layer's representation (10). figure 1: relationship between artificial intelligence (ai), machine learning (ml), and deep learning (dl). created with biorender.com the surge in artificial intelligent systems has generated significant interest in their applications within the medical domain (11). recent times have witnessed a swift integration of ai into medical practices, driven by the goal of augmenting patient care through swifter procedures and enhanced precision, thereby laying the foundation for elevated healthcare standards. this development marks a pivotal stride towards healthcare advancement. ai's seamless integration into the medical landscape encompasses a broad spectrum of informatics techniques, spanning from the intricacies of deep learning-driven information management to the comprehensive oversight of health management systems, notably electronic health records (12). this comprehensive expansion extends to the domain of clinical decision-making, offering valuable guidance to physicians, while also embracing the innovative deployment of robots to assist both elderly patients and attending surgeons. within this transformative framework, machine learning assumes a prominent role, actively engaging in the assessment of radiological images, pathology slides, and electronic medical records (emr) of patients. this concerted endeavor enhances diagnostic and treatment paradigms, amplifying physician capabilities, and significantly contributing to the overall advancement of healthcare quality (13). this paper meticulously examines the major applications of artificial intelligence in the field of cancer medicine. ranging from its role in imaging enhancement to its prowess in predictive analytics, these applications showcase ai's multifaceted potential in transforming cancer care. current challenges in cancer care despite remarkable progress in cancer care over the years, the field continues to grapple with certain challenges that demand attention and innovative solutions. these challenges underscore the importance of ongoing research and collaborative efforts to further enhance cancer treatment and patient outcomes. the interplay of rapid urbanization, lifestyle choices, and rising life expectancy stands as a significant driving force behind the changing landscape of cancer incidence rates. according to globocan predictions, the number of cancer cases is expected to reach 28.4 million by 2040 (14). globally, female breast cancer has now surpassed lung cancer as the most prevalent cancer (11.7%), closely followed by lung (11.4%), colorectal (10.0%), prostate (7.3%), and stomach (5.6%) cancers. lung cancer stands as the leading cause for death, accounting for 1.8 million deaths (18%), followed by colorectal (9.4%), liver (8.3%), stomach (7.7%), and female breast (6.9%) cancers. among men, lung, prostate, and colorectal cancers are the most prevalent, while breast, colorectal, and lung cancers are the leading types among women. in fact, cancer cases are expected to rise significantly in lower-resource settings and countries with a low human development index (hdi), while the burden decreases with higher national hdi levels (15). in many high-income countries (hics), cancer-screening programs like mammography for breast cancer, low-dose ct scan for lung cancer and colonoscopy for colorectal cancer are challenging to implement in lowand middleincome countries (lmics) due to limited resources and insufficient trained personnel. this calls for the development of technology-driven, cost-effective, and user-friendly point-of-care screening and diagnostic tools (16). cancer immunotherapy is a well-established and crucially important approach in the treatment of cancer patients. over the past decade, therapeutic advancements in cancer immunotherapy (cit) have swiftly emerged, underscoring the vital interplay between the human immune system and cancer. however, it is essential to acknowledge that only a minority of patients experience sustainable lifechanging survival outcomes. cancer immunotherapy faces several challenges, including uncertainties in effectively translating preclinical findings into successful clinical applications and identifying the best combinations of immune-based therapies personalized to each patient's needs (17). additionally, special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 3 2023, vol. 3 no. s1 1--10 despite substantial advancements, small-molecule targeted anti-cancer drugs still confront several hurdles, such as low response rates and the development of drug resistance (18). efforts to address these challenges are critical to further improve cancer treatment outcomes and advancing the frontier of cancer care. these challenges really highlight the urgent need for better treatment and prediction methods in cancer care. therefore, prioritizing ai-driven innovative approaches in technology-based, costeffective, and user-friendly point-of-care screening and diagnostics can bridge cancer care gaps globally. addressing disparities and strategic healthcare resource allocation are essential in combating the growing burden in vulnerable regions. role of artificial intelligence in cancer care the potential of ai applications is immense, as they can enhance clinician decision-making, optimize clinical care processes, improve patient outcomes, and lead to reduced healthcare costs (19). the rapid expansion of artificial intelligence (ai) within the healthcare sector has been remarkable over the past decade. ai applications have demonstrated their potential in transforming healthcare by leveraging clinical data to uncover valuable information (figure 2). through aiding healthcare providers in various critical tasks, such as disease diagnosis, patient triage, risk analysis, and surgical procedures, ai has become an indispensable tool in enhancing overall clinical care and patient outcomes (20). ai has achieved prominence as a widely adopted technology with a diverse array of multifaceted applications across various fields–which will be gone over in the following paragraphs. ai has rapidly become an integral component in various healthcare applications, spanning drug discovery, remote patient monitoring, medical diagnostics and imaging, risk management, wearables, virtual assistants, and hospital management (21). its diverse and everexpanding utilization in these areas showcases the transformative potential of ai technology in revolutionizing the healthcare landscape. as ai continues to evolve and intertwine with healthcare practices, it holds the promise of enhancing efficiency, accuracy, and overall patient care, ushering in a new era of medical innovation. figure 2: applications of ai in oncology to solve healthcare issues and predict optimal treatment outcomes. created with biorender.com cancer imaging and diagnosis ai's remarkable ability to identify intricate patterns in medical images revolutionizes image interpretation, making it a quantifiable and reproducible process. additionally, ai uncovers information imperceptible to human eyes, enhancing clinical decision-making (22). conventional machine learning and deep learning techniques are used for lesion detection and classification, aiming to reduce reading time and enhance accuracy in differentiating between benign and malignant cases (23). by integrating diverse data streams, including radiographic images, genomics, pathology, electronic health records, and social networks, ai empowers the development of powerful diagnostic systems with farreaching potential. advancements in computer programs have led to the development and approval of clinical tools such as computer-aided detection (cad) or computer-assisted detection, assisting radiologists in detecting potential abnormalities on diagnostic radiology exams, thereby reducing false negative rates (24). by incorporating cad into clinical practice, the accuracy and reliability of diagnostic radiology are enhanced, leading to improved patient outcomes and more effective care. radiology traditionally relies on skilled physicians' visual assessments, but this approach can be subjective, influenced by their education and experience. in contrast, ai excels in recognizing intricate patterns within imaging data, enabling an objective and automated quantitative assessment (21). integrating ai as a supportive tool enhances radiology assessments, advancing patient care and outcomes. this collaborative approach, combining human expertise and ai-driven precision, elevates radiological practices to new heights of efficiency and effectiveness (25). as ai continues to evolve in radiology, its role as an invaluable ally in disease detection, characterization, and monitoring becomes increasingly evident, promising a future of special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 4 2023, vol. 3 no. s1 1--10 precision and excellence in medical imaging and diagnosis. artificial intelligence-driven precision medicine the integration of artificial intelligence (ai) and precision medicine stands poised to catalyze a profound transformation within the healthcare landscape. precision medicine introduces a paradigm shift, aiming to advance the healthcare model where diagnostics, prevention, and treatment strategies are meticulously tailored to an individual's unique genetic, environmental, and lifestyle attributes (26). this approach is instrumental in discerning distinctive patient phenotypes marked by uncommon treatment responses and specific healthcare requirements. leveraging intricate computational capabilities, ai serves as a catalyst, enabling sophisticated reasoning, learning, and augmented intelligence, thus empowering clinical decision-makers to navigate complex healthcare scenarios and deliver personalized care with heightened efficacy. the discovery potential inherent in precision medicine augments our understanding of unexplored therapeutic avenues, extending the boundaries of healthcare possibilities (27). critical to the personalization of medical care are the diverse data collection and analytical technologies that underpin precision medicine's core principles (28). real-time treatment recommendations hinge upon the precision of machine-learning algorithms that anticipate patients' potential medication requirements based on their genomic profiles. at the heart of tailored drug administration lies preemptive patient genotyping, ensuring optimal therapeutic interventions (29). this paradigm underscores a seminal example of ai and precision medicine synergy, manifesting in the seamless convergence of ai techniques with the meticulous interpretation of high-throughput genomic data (30). predictive analytics and prognosis artificial intelligence (ai) is increasingly utilized to develop cancer prediction models (31). various methods, including statistical, machine learning, and deep learning approaches, have been employed to enhance prediction accuracy (32-33). machine learning (ml) algorithms can leverage extensive screening data to develop robust models that can predict drug responses in cancer patients (34). the incorporation of various data types demands more resources than analyzing individual data types alone, requiring modeling algorithms capable of comprehending vast amounts of intricate features (35). as a result, ai-driven algorithms are increasingly employed to automate cancer prediction by identifying the development of cancer and even characterizing it (36). a study that was conducted showed the proficiency of these machine-learning approaches in cancer prediction (36). in this study, differences in clinicopathological characteristics were observed between the two datasets, with a specific dataset showing superior survival rates. in predicting 5-year survival, the machine learning model employing light gradient boosting surpassed conventional staging methods. notably, age, examined lymph nodes, and tumor size emerged as pivotal factors shaping the model's performance. the validation set further provided sensitivity and positive predictive values for survival prediction. this underscores the ml-based model's remarkable advancement, surpassing conventional staging techniques in providing highly precise individualized survival estimations (37). in addition to machine learning techniques, two primary factors contribute to the attractiveness of deep learning in computational biology (38). first and foremost, this potent model class has the capacity to approximate virtually any input-to-output mapping with sufficient data. for instance, when predicting transcription factor binding locations, there is no necessity to confine the model's expressivity to a single sequence motif (39). notably, deep learning models have been harnessed for prediction purposes in a conducted study (40). a deep learning model (deepdr) was made to forecast drug responses in cancer cells and tumors. deepdr seamlessly integrates mutation and expression data, comprising three pivotal components: one for mutation comprehension, another for expression analysis, and a final component for drug response prediction. its predictive prowess extends to 265 drugs, envisaging their efficacy grounded in genetic and expression profiles. rigorously tested on 622 cancer cell lines, deepdr showcased remarkable performance, surpassing existing methods in drug response prediction. demonstrating its breadth, the model further predicted drug responses across 9059 tumors spanning 33 cancer types. in doing so, it unveiled known efficacious drugs and unearthed novel candidates, shedding light on drug mechanisms, resistance patterns, and proposing a promising therapeutic avenue for gliomas and blood cancers. drug discovery and development artificial intelligence (ai) presents a transformative potential in reshaping both drug design strategies and patient treatment paradigms. the challenges encompassing drug design, including time constraints, production costs, inefficient target delivery, and imprecise dosing, have propelled the special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 5 2023, vol. 3 no. s1 1--10 exploration of ai-driven solutions (41). traditional drug development barriers, underscored by intricacies in big data handling, have found resolution through ai integration, transcending conventional computational approaches (42). this synergy has yielded expedited drug candidate development, fostering cost-effective and structured solutions within notably reduced timeframes (43). complementing this, emerging machine learning techniques, notably deep learning, have harnessed vast data reservoirs to predict molecular structures, in-vivo vs. in-vitro characteristics, and outcomes, streamlining drug discovery without compromising efficiency (44). ai's potential extends to revolutionary platforms like the quadratic phenotypic optimization platform (qpop), which, unlike conventional methods, tailors drug combinations to specific disease models or patient profiles based on empirical data, transcending preconceived mechanistic assumptions (45). in parallel, ai models, spanning patient stratification, pathophysiological casualties, drug candidate design, and virtual patient predictions, hold paramount significance (46-47). notably, ai's prowess in delineating structure-activity relationships (sar) and exploiting massive sequencing data, such as nextgeneration sequencing (ngs), illuminates novel drug target identification, augmenting drug discovery pathways (48). within the ai arsenal, artificial neural networks, deep neural networks, support vector machines, classification and regression techniques, generative adversarial networks, symbolic learning, and meta-learning algorithms have been harnessed to elevate drug design and discovery (49). the culmination of individual patient attributes and extensive drug candidate predictions within these models fosters a new era of personalized and optimized treatment strategies, revolutionizing disease management practices (50-51). as ai continues to reshape drug design and patient-oriented approaches, the potential for personalized and precision medicine stands poised for unprecedented advancement. challenges and limitations of artificial intelligence in cancer care while ai holds promise in bolstering the healthcare sector and improving cancer care, apprehensions arise about the potential difficulty in validating and questioning ai-mediated decisions, which might lead to unconventional outcomes (52). the instances of ai integration in healthcare serve as pivotal examples, highlighting the significance of assessing both the benefits and risks associated with emerging ai-driven systems (53). the primary hurdle in advancing clinical ai applications in oncology, and healthcare in general, lies in data constraints, encompassing both quality and quantity aspects. pertinent challenges encompass data curation, aggregation transparency, potential bias, and reliability concerns (54). the deployment of deep learning in precision oncology faces obstacles such as scarce phenotypically rich data and the imperative for more interpretable deep learning models (55). ethical, copyright, transparency, and legal issues, alongside the risk of biases, plagiarism, inaccuracies, limited knowledge, incorrect citations, and cybersecurity vulnerabilities, underscore ai's limitations (56). the issues of ai model interpretability, trust, reproducibility, and generalizability have garnered substantial attention, with growing recognition of biases in demographic factors like sex and ethnicity (57). for instance, an ai tool for using 129,450 images for detecting skin cancer displayed parity with dermatologists but faced criticism for underrepresentation of darker skin tones, raising concerns about reproducibility and applicability (5859). additionally, the meticulous curation and storage of data for machine learning models, along with evolving data stewardship expectations, further complicate ai advancement (60). fostering ai applications in cancer care demands a focus on clinical validity, utility, and usability. achieving this entails a patient-centric, clinical decision-oriented approach to model development and assessment (61). from challenges in training machine learning systems to accountability uncertainties, the incremental implementation of ai remains complex (62). moreover, physician comprehension of ai's potential remains a significant aspect that needs to be addressed (63). this domain undoubtedly holds immense promise, yet it is marked by notable gaps and ambiguities requiring attention. the primary hurdle lies not in the rapid technological advancements, which continually unveil new application areas, but rather in the deficient legal framework. inadequate regulations, coupled with political, ethical, and financial intricacies, underscore the challenge (64). hence, a collaborative effort among technologists, policymakers, and ethicists becomes paramount. the imperative is to establish a robust legal structure that guides innovation while upholding ethical norms. this harmonious convergence has the potential to unleash the realm's possibilities, dissipating uncertainties and nurturing responsible advancement. special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 6 2023, vol. 3 no. s1 1--10 ethical and regulatory considerations artificial intelligence (ai), while transforming the medical landscape, raises significant ethical considerations. while ai holds potential in healthcare, its implementation necessitates careful oversight akin to physician conduct. to ensure safe utilization and assessment of ai technology, regulatory frameworks are imperative, coupled with research into its medical capabilities and constraints (63). given that patients interact with physicians during vulnerable moments, maintaining sensitivity to this fact is crucial (65). protecting health data, which encompasses private patient and caregiver details and medical histories, is paramount. breaches could lead to personal repercussions such as bullying, higher insurance premiums, and job loss (66-67). security, privacy, and trust are non-negotiable (68). ai will not supplant human roles entirely, but integration into physicians' routines can be pivotal (68). transitioning towards personalized, evidencebased patient management warrants rigorous evaluations of ai technologies, particularly in cancer risk or management scenarios (68). ethical concerns include the opaque nature of ai decisions, its influence on patient engagement and shared decision-making, and the allocation of responsibility if ai predictions falter (69). other ethical issues encompass informed data consent, safety, transparency, algorithmic fairness, biases, and data privacy (65). with ai gaining prominence in high-stakes contexts, ensuring accountable, equitable, and transparent ai design and governance is paramount (70). transparency hinges on accessible and comprehensible information (71). further interdisciplinary collaboration and research hold potential to markedly enhance patient care quality, rebalance clinician workloads, and revolutionize medical practice (72). this dynamic journey toward ethical ai integration demands collective dedication and thoughtful navigation. conclusion and discussion the dynamic landscape of cancer care poses challenges that necessitate innovative and collaborative solutions. factors like urbanization, shifting lifestyles, and extended longevity contribute to changing cancer rates, underlining the urgency of targeted interventions and equitable healthcare access. the complexities of cancer prevalence across regions and demographics further underscore the need for tailored approaches and resource allocation. however, implementing effective cancer screening and diagnostics remains particularly daunting in resourceconstrained settings, emphasizing the demand for technology-driven and user-friendly solutions. challenges persist in immunotherapy and targeted drug development, requiring solutions for issues such as translation and resistance. artificial intelligence (ai) emerges as a potent tool to address these challenges and reshape cancer care paradigms. integrating ai-driven innovations into point-of-care screening and diagnostics has the potential to bridge global cancer care gaps, especially in resource-limited regions. beyond diagnosis and treatment, ai enhances clinician decision-making, streamlines clinical processes, and drives cost reduction. the rapid growth of ai across healthcare domains, from drug discovery to medical imaging, underscores its transformative impact. ai's proficiency in pattern recognition catalyzes a revolution in radiology, enhancing precise and efficient image interpretation and elevating patient care. moreover, ai's synergy with precision medicine introduces a pivotal shift, enabling tailored treatments grounded in individual genetic and environmental variables. nonetheless, the substantial potential of ai must be approached with ethical considerations and vigilance. prioritizing privacy, security, transparency, and bias mitigation is pivotal to ensure ai's equitable and responsible deployment in healthcare. collaborative efforts among technologists, policymakers, and ethicists are essential to establish a robust regulatory framework that guides ai innovation while upholding ethical norms. addressing concerns about data quality, model interpretability, and accountability remains imperative in ai's ongoing evolution. in light of these prospects and challenges, the integration of ai into cancer care holds promise for overcoming obstacles and reshaping patient outcomes. by harnessing ai's capabilities and fostering collaboration, the healthcare community can strive for personalized, effective, and ethically sound cancer care on a global scale. this transformative journey demands a comprehensive approach, uniting technological innovation, regulatory diligence, and ethical contemplation. as we navigate this path, the convergence of ai and cancer care stands as a beacon of hope, promising a future marked by enhanced patient well-being and advanced medical progress. special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 7 2023, vol. 3 no. s1 1-10 references 1. yin w, wang j, jiang l, james kang y. cancer and stem cells. exp biol med (maywood). 2021;246(16):1791-1801. doi:10.1177/15353702211005390 2. hazafa a, rehman ku, jahan n, jabeen z. the role of polyphenol (flavonoids) compounds in the treatment of cancer cells. nutr cancer. 2020;72(3):386397. doi:10.1080/01635581.2019.1637006 3. siegel rl, miller kd, fuchs he, jemal a. cancer statistics, 2021 [published correction appears in ca cancer j clin. 2021 jul;71(4):359]. ca cancer j clin. 2021;71(1):7-33. doi:10.3322/caac.21654 4. siegel rl, miller kd, wagle ns, jemal a. cancer statistics, 2023. ca cancer j clin. 2023;73(1):17-48. doi:10.3322/caac.21763 5. radkiewicz c, andersson tm, lagergren j. reranking cancer mortality using years of life lost. jnci cancer spectr. 2023;7(3):pkad038. doi:10.1093/jncics/pkad038 6. shimizu h, nakayama ki. artificial intelligence in oncology. cancer sci. 2020;111(5):1452-1460. doi:10.1111/cas.14377 7. choi ry, coyner as, kalpathy-cramer j, chiang mf, campbell jp. introduction to machine learning, neural networks, and deep learning. transl vis sci technol. 2020;9(2):14. published 2020 feb 27. doi:10.1167/tvst.9.2.14 8. deo rc. machine learning in medicine. circulation. 2015;132(20):1920-1930. doi:10.1161/circulationaha.115. 001593 9. lecun y, bengio y, hinton g. deep learning. nature. 2015;521(7553):436444. doi:10.1038/nature14539 10. esteva a, robicquet a, ramsundar b, et al. a guide to deep learning in healthcare. nat med. 2019;25(1):24-29. doi:10.1038/s41591-018-0316-z 11. rajpurkar p, chen e, banerjee o, topol ej. ai in health and medicine. nat med. 2022;28(1):31-38. doi:10.1038/s41591021-01614-0 12. hamet p, tremblay j. artificial intelligence in medicine. metabolism. 2017;69s:s36-s40. doi:10.1016/j.metabol.2017.01.011 13. mintz y, brodie r. introduction to artificial intelligence in medicine. minim invasive ther allied technol. 2019;28(2):73-81. doi:10.1080/13645706.2019.1575882 14. sung h, ferlay j, siegel rl, et al. global cancer statistics 2020: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin. 2021;71(3):209-249. doi:10.3322/caac.21660 15. soerjomataram i, bray f. planning for tomorrow: global cancer incidence and the role of prevention 2020-2070. nat rev clin oncol. 2021;18(10):663-672. doi:10.1038/s41571-021-00514-z 16. deo svs, sharma j, kumar s. globocan 2020 report on global cancer burden: challenges and opportunities for surgical oncologists. ann surg oncol. 2022;29(11):64976500. doi:10.1245/s10434-022-12151-6 17. hegde ps, chen ds. top 10 challenges in cancer immunotherapy. immunity. 2020;52(1):17-35. doi:10.1016/j.immuni.2019.12.011 18. zhong l, li y, xiong l, et al. small molecules in targeted cancer therapy: advances, challenges, and future perspectives. signal transduct target ther. 2021;6(1):201. published 2021 may 31. doi:10.1038/s41392-02100572-w 19. yin j, ngiam ky, teo hh. role of artificial intelligence applications in real-life clinical practice: systematic review. j med internet res. 2021;23(4):e25759. published 2021 apr 22. doi:10.2196/25759 20. he j, baxter sl, xu j, xu j, zhou x, zhang k. the practical implementation of artificial intelligence technologies in medicine. nat med. 2019;25(1):30-36. doi:10.1038/s41591-018-0307-0 21. hosny a, parmar c, quackenbush j, schwartz lh, aerts hjwl. artificial special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 8 2023, vol. 3 no. s1 1-10 intelligence in radiology. nat rev cancer. 2018;18(8):500-510. doi:10.1038/s41568-018-0016-5 22. bi wl, hosny a, schabath mb, et al. artificial intelligence in cancer imaging: clinical challenges and applications. ca cancer j clin. 2019;69(2):127-157. doi:10.3322/caac.21552 23. mendes j, domingues j, aidos h, garcia n, matela n. ai in breast cancer imaging: a survey of different applications. j imaging. 2022;8(9):228. published 2022 aug 26. doi:10.3390/jimaging8090228 24. castellino ra. computer aided detection (cad): an overview. cancer imaging. 2005;5(1):17-19. published 2005 aug 23. doi:10.1102/14707330.2005.0018 25. aerts hj. the potential of radiomicbased phenotyping in precision medicine: a review. jama oncol. 2016;2(12):1636-1642. doi:10.1001/jamaoncol.2016.2631 26. aronson sj, rehm hl. building the foundation for genomics in precision medicine. nature. 2015;526(7573):336342. doi:10.1038/nature15816 27. azad rk, shulaev v. metabolomics technology and bioinformatics for precision medicine. brief bioinform. 2019;20(6):1957-1971. doi:10.1093/bib/bbx170 28. johnson kb, wei wq, weeraratne d, et al. precision medicine, ai, and the future of personalized health care. clin transl sci. 2021;14(1):86-93. doi:10.1111/cts.12884 29. schildcrout js, shi y, danciu i, et al. a prognostic model based on readily available clinical data enriched a preemptive pharmacogenetic testing program. j clin epidemiol. 2016;72:107-115. doi:10.1016/j.jclinepi.2015.08.028 30. deep learning for genomics. nat genet. 2019;51(1):1. doi:10.1038/s41588-0180328-0 31. swanson k, wu e, zhang a, alizadeh aa, zou j. from patterns to patients: advances in clinical machine learning for cancer diagnosis, prognosis, and treatment. cell. 2023;186(8):17721791. doi:10.1016/j.cell.2023.01.035 32. kalafi ey, nor nam, taib na, ganggayah md, town c, dhillon sk. machine learning and deep learning approaches in breast cancer survival prediction using clinical data. folia biol (praha). 2019;65(5-6):212-220. 33. ganggayah md, taib na, har yc, lio p, dhillon sk. predicting factors for survival of breast cancer patients using machine learning techniques. bmc med inform decis mak. 2019;19(1):48. published 2019 mar 22. doi:10.1186/s12911-019-0801-4 34. baptista d, ferreira pg, rocha m. deep learning for drug response prediction in cancer. brief bioinform. 2021;22(1):360-379. doi:10.1093/bib/bbz171 35. libbrecht mw, noble ws. machine learning applications in genetics and genomics. nat rev genet. 2015;16(6):321-332. doi:10.1038/nrg3920 36. osman mh, mohamed rh, sarhan hm, et al. machine learning model for predicting postoperative survival of patients with colorectal cancer. cancer res treat. 2022;54(2):517-524. doi:10.4143/crt.2021.206 37. skrede oj, de raedt s, kleppe a, et al. deep learning for prediction of colorectal cancer outcome: a discovery and validation study. lancet. 2020;395(10221):350-360. doi:10.1016/s0140-6736(19)32998-8 38. issa nt, stathias v, schürer s, dakshanamurthy s. machine and deep learning approaches for cancer drug repurposing. semin cancer biol. 2021;68:132-142. doi:10.1016/j.semcancer.2019.12.011 39. jones w, alasoo k, fishman d, parts l. computational biology: deep learning. emerg top life sci. 2017;1(3):257-274. doi:10.1042/etls20160025 40. chiu yc, chen hh, zhang t, et al. predicting drug response of tumors from integrated genomic profiles by deep neural networks [published correction appears in bmc med genomics. 2019 aug 12;12(1):119]. bmc med genomics. 2019;12(suppl 1):18. published 2019 jan 31. doi:10.1186/s12920-018-0460-9 41. gupta r, srivastava d, sahu m, tiwari s, ambasta rk, kumar p. artificial intelligence to deep learning: machine intelligence approach for drug special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 9 2023, vol. 3 no. s1 1-10 discovery. mol divers. 2021;25(3):1315-1360. doi:10.1007/s11030-021-10217-3 42. wang l, alexander ca. big data analytics in medical engineering and healthcare: methods, advances and challenges. j med eng technol. 2020;44(6):267-283. doi:10.1080/03091902.2020.1769758 43. tripathi mk, nath a, singh tp, ethayathulla as, kaur p. evolving scenario of big data and artificial intelligence (ai) in drug discovery. mol divers. 2021;25(3):1439-1460. doi:10.1007/s11030-021-10256-w 44. zhao l, ciallella hl, aleksunes lm, zhu h. advancing computer-aided drug discovery (cadd) by big data and datadriven machine learning modeling. drug discov today. 2020;25(9):16241638. doi:10.1016/j.drudis.2020.07.005 45. zhang l, tan j, han d, zhu h. from machine learning to deep learning: progress in machine intelligence for rational drug discovery. drug discov today. 2017;22(11):1680-1685. doi:10.1016/j.drudis.2017.08.010 46. moingeon p. artificial intelligencedriven drug development against autoimmune diseases. trends pharmacol sci. 2023;44(7):411-424. doi:10.1016/j.tips.2023.04.005 47. workman p, antolin aa, al-lazikani b. transforming cancer drug discovery with big data and ai. expert opin drug discov. 2019;14(11):1089-1095. doi:10.1080/17460441.2019.1637414 48. qin d. next-generation sequencing and its clinical application. cancer biol med. 2019;16(1):4-10. doi:10.20892/j.issn.20953941.2018.0055 49. zhu h. big data and artificial intelligence modeling for drug discovery. annu rev pharmacol toxicol. 2020;60:573-589. doi:10.1146/annurev-pharmtox010919-023324 50. chopra h, baig aa, gautam rk, kamal ma. application of artificial intelligence in drug discovery. curr pharm des. 2022;28(33):2690-2703. doi:10.2174/138161282866622060814 1049 51. rashid mbma, chow ek. artificial intelligence-driven designer drug combinations: from drug development to personalized medicine. slas technol. 2019;24(1):124-125. doi:10.1177/2472630318800774 52. liyanage h, liaw st, jonnagaddala j, et al. artificial intelligence in primary health care: perceptions, issues, and challenges. yearb med inform. 2019;28(1):41-46. doi:10.1055/s-00391677901 53. küster d, schultz t. künstliche intelligenz und ethik im gesundheitswesen – spagat oder symbiose? [artificial intelligence and ethics in healthcare-balancing act or symbiosis?]. bundesgesundheitsblatt gesundheitsforschung gesundheitsschutz. 2023;66(2):176183. doi:10.1007/s00103-022-03653-5 54. norgeot b, quer g, beaulieu-jones bk, et al. minimum information about clinical artificial intelligence modeling: the mi-claim checklist. nat med. 2020;26(9):1320-1324. doi:10.1038/s41591-020-1041-y 55. tran ka, kondrashova o, bradley a, williams ed, pearson jv, waddell n. deep learning in cancer diagnosis, prognosis and treatment selection. genome med. 2021;13(1):152. published 2021 sep 27. doi:10.1186/s13073-021-00968-x 56. sallam m. chatgpt utility in healthcare education, research, and practice: systematic review on the promising perspectives and valid concerns. healthcare (basel). 2023;11(6):887. published 2023 mar 19. doi:10.3390/healthcare11060887 57. beam al, manrai ak, ghassemi m. challenges to the reproducibility of machine learning models in health care. jama. 2020;323(4):305-306. doi:10.1001/jama.2019.20866 58. esteva a, kuprel b, novoa ra, et al. dermatologist-level classification of skin cancer with deep neural networks [published correction appears in nature. 2017 jun 28;546(7660):686]. nature. 2017;542(7639):115-118. doi:10.1038/nature21056 59. zou j, schiebinger l. ai can be sexist and racist it's time to make it fair. nature. 2018;559(7714):324-326. doi:10.1038/d41586-018-05707-8 special edition: junior commentary https://doi.org/10.47488/dhrp.v3is1.95 dhr proceedings ǀ http://dhrproceedings.org 10 2023, vol. 3 no. s1 1-10 60. wilkinson md, dumontier m, aalbersberg ij, et al. the fair guiding principles for scientific data management and stewardship [published correction appears in sci data. 2019 mar 19;6(1):6]. sci data. 2016;3:160018. published 2016 mar 15. doi:10.1038/sdata.2016.18 61. kann bh, hosny a, aerts hjwl. artificial intelligence for clinical oncology. cancer cell. 2021;39(7):916927. doi:10.1016/j.ccell.2021.04.002 62. chomutare t, tejedor m, svenning to, et al. artificial intelligence implementation in healthcare: a theory-based scoping review of barriers and facilitators. int j environ res public health. 2022;19(23):16359. published 2022 dec 6. doi:10.3390/ijerph192316359 63. aung yym, wong dcs, ting dsw. the promise of artificial intelligence: a review of the opportunities and challenges of artificial intelligence in healthcare. br med bull. 2021;139(1):415. doi:10.1093/bmb/ldab016 64. pashkov vm, harkusha ao, harkusha yo. artificial intelligence in medical practice: regulative issues and perspectives. wiad lek. 2020;73(12 cz 2):2722-2727. 65. naik n, hameed bmz, shetty dk, et al. legal and ethical consideration in artificial intelligence in healthcare: who takes responsibility?. front surg. 2022;9:862322. published 2022 mar 14. doi:10.3389/fsurg.2022.862322 66. thapa c, camtepe s. precision health data: requirements, challenges and existing techniques for data security and privacy. comput biol med. 2021;129:104130. doi:10.1016/j.compbiomed.2020.10413 0 67. sheikh a, anderson m, albala s, et al. health information technology and digital innovation for national learning health and care systems. lancet digit health. 2021;3(6):e383-e396. doi:10.1016/s2589-7500(21)00005-4 68. rompianesi g, pegoraro f, ceresa cd, montalti r, troisi ri. artificial intelligence in the diagnosis and management of colorectal cancer liver metastases. world j gastroenterol. 2022; 28(1):108-122. doi:10.3748/wjg.v28.i1.108 69. hunter b, hindocha s, lee rw. the role of artificial intelligence in early cancer diagnosis. cancers (basel). 2022;14(6):1524. published 2022 mar 16. doi:10.3390/cancers14061524 70. morley j, machado ccv, burr c, et al. the ethics of ai in health care: a mapping review. soc sci med. 2020;260:113172. doi:10.1016/j.socscimed.2020.113172 71. char ds, abràmoff md, feudtner c. identifying ethical considerations for machine learning healthcare applications. am j bioeth. 2020;20(11):7-17. doi:10.1080/15265161.2020.1819469 72. xu l, sanders l, li k, chow jcl. chatbot for health care and oncology applications using artificial intelligence and machine learning: systematic review. jmir cancer. 2021;7(4):e27850. published 2021 nov 29. doi:10.2196/27850 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.80 dhr proceedings ǀ http://dhrproceedings.org 7 2023, vol. 2 no. s2 7-14 commentary factors/maternal behaviors that affect fetal development vladislava milova1,2, han phung1,2, victoria cazares1,3, victoria guajardo1,2, sienna herndon1,2, celeste garza1,4, janessa trevino1,2, amy aldaz1,2, kamyshla galvan1,4, ximena munoz1,4, jorge gonzalez1,2 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 nikki rowe high school, tx 3 psja collegiate school of health professions, tx 4 psja southwest high school, tx received: june 16, 2023 accepted for publication: october 25, 2023 published: november 16, 2023 introduction since the dawn of time, birth defects have always been a major issue. birth defects can be described as a complication that occurs during fetal development in the mother’s body1. according to the centers for disease control and prevention (cdc), one in thirty-three neonates are born with a birth defect.2 these congenital anomalies can eventually advance to emergency situations as their life progresses.2 some of the factors that may affect birth outcomes are viruses, the influence of the environment, genetics (interbreeding), and complications during pregnancy/labor. other contributing factors to fetal development include behaviors such as drugs, alcohol, smoking, and diet. since 20% of newborn fatalities are due to birth defects, it is vital for mothers to be aware of these factors and behaviors.3 therefore, our goal is to provide information to implement preventative measures for outcomes of prenatal malformations. alcohol consuming alcohol during fetal development causes a number of alcohol-induced defects known as fetal alcohol spectrum disorder (fasd).4 alcohol can affect the fetus in its early stages even if the woman is not aware she is pregnant. it has been reported that 2030% of women drink at some point during the first trimester. drinking may cause stunted growth of the brain resulting in educational, behavioral, medical, and social-related problems. types of educational issues may include but are not limited to working memory, problem-solving, and impairments in reading, spelling, and math skills.5 a child with fasd may experience aggressive behavior, extreme mood changes, hyperactivity, and impulsiveness.6 some medical issues include narrow eye openings, a smooth area between the lip and nose, and a thin upper lip.7 social-related problems include unresponsiveness to social cues and the inability to keep/make friends.8 drugs & smoking north america is living through a rapid increase in opioids and cannabis consumption, including prescription and non-prescription drugs.9 since 1999, the incidence of nas has increased by 300%.9 pregnant women are not immune to disorders resulting from drugs. it is estimated that 10% of births each year are affected negatively by illicit drug use.9 during the nine-month pregnancy process, drug use may not only be addictive but can affect the mother and the fetus negatively. there are many types of medication that can be used in a positive manner, but the mothers using these medications can become reliant on them. opioids are used to manage pain, special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.80 dhr proceedings ǀ http://dhrproceedings.org 8 2023, vol. 2 no. s2 7-14 which can lead to addictive behaviors from the mother, affecting the fetus, specifically causing the newborn also to be dependent on the specific drug used. other consequences include labor miscarriages, premature delivery, cognitive developmental problems, abnormal brain structure, and function, as well as fetal stress.10 the prevalence of drug use in pregnancy is not accurately represented due to the small amount of well-validated tests.9 there are no specific guidelines for drug screening during pregnancy, so the number of affected births is unknown.9 cooperation from the mothers is also very limited. only 5% of women admit to the doctor that they were taking drugs during pregnancy.9 this can lead to invalidated results and inaccurate diagnoses. although the amount is small, tests are still available to see if the mother is misusing drugs. various tissues are tested for drug use, including maternal blood, urine, umbilical cord tissue, and hair.9 other tests include simple spectrophotometry or sophisticated analytical hplc.9 certain us states, including tennessee, alabama, and south carolina, have charged the women with child abuse if they are found addicted to drugs, and multiple women have been arrested if their drug screens are positive.9 women are at the highest risk of developing a substance use disorder during their developmental age (18-24).11 in a national survey, taken in 2012 in the united states, results show that 5.9% of women use illicit drugs, and 15.9% smoke cigarettes, resulting in 380,000 offspring being exposed to illicit drugs and over one million being exposed to tobacco, though 54% of women who smoke quit before pregnancy.11 the most commonly used substances during pregnancy are tobacco and nicotine, which if used, expose the newborn to the risk of health problems, learning disabilities, and brain developmental abnormalities. studies of the acog clinical research show that children born to smoker women during or before pregnancy are at risk of bone fractures, asthma, child respiratory infections, as well as hearing loss. drug consumption can imply a young woman with health complications. drug abuse during pregnancy may cause many problems such as miscarriage, preterm labor, birth defects, stillbirth, withdrawal symptoms for the mother and baby after birth, a high risk of sudden infant death syndrome (sids), poor fetal growth rate, and cognitive and behavioral problems.12 also, women that inject drugs during birth are at a higher risk of contracting hiv, which is commonly passed down to their babies.12 non-prescription drugs are not the only substances that present risks to the woman’s health. prescription drugs, specifically prescribed opioids, are also at risk to women, with many reports of women getting addicted to prescription drugs and painkillers.12 these drugs can also cause serious withdrawal symptoms in newborn babies.12 this is commonly known as neonatal abstinence syndrome (nas). neonatal abstinence syndrome (nas) is a mass of symptoms that indicate a newborn is going through withdrawal symptoms because of exposure to opioids during the mother’s pregnancy.13 the most common drugs associated with nas are heroin, codeine, fentanyl, oxycodone, and methadone.13 some symptoms of neonatal abstinence syndrome are vomiting, fever, sleep problems, seizures, rapid breathing, and many more.13 nas is treatable. many doctors recommend taking medicine that helps with withdrawal symptoms, injecting fluids through the vein of the newborn so it does not get dehydrated, and being fed higher-calorie baby formula.14 although many states have introduced counseling and pregnancy-specific materials to help mothers that are dependent on a certain drug or smoke consistently, some women continue to use tobacco products and drugs.15 many surveys show that it is also recommended that clinicians individualize care by providing psychosocial, behavioral, and pharmacotherapy interventions to mothers that are either addicted to drugs or that smoke.15. many physicians and doctors are working on significantly decreasing the amount of drug use in north america, not just in pregnant women, but in the whole population. diet women have specific nutritional requirements during pregnancy and breastfeeding when the nutritional vulnerability is most common.16 nutrients include carbohydrates (sugars), lipids (fats), proteins, specific vitamins, minerals, and water.17 poor diets lacking nutrients like iodine, zinc, folate, and calcium increase the risk of anemia, pre-eclampsia, and hemorrhage in mothers and can cause the child to be stillborn, and have a low birthweight unicef estimates low birthweight affects about 20 million newborns each year and can create many developmental problems.16 there are many foods that should be avoided during pregnancy. these foods can cause certain birth defects in the fetus and can increase the risk of foodborne illnesses for the mother. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.80 dhr proceedings ǀ http://dhrproceedings.org 9 2023, vol. 2 no. s2 7-14 seafood can provide an amazing source of protein and omega-3 fatty acids for the mother. protein and fatty acids can positively affect the newborn's brain and eye development. however, certain shellfish have high levels of mercury which can harm the newborn’s nervous system.18 the older and bigger the fish, the more mercury it is likely to contain.18 the fda encourages mothers to stay away from bigeye tuna, marlin, king mackerel, shark, and wordfish to avoid the risk of these problems. any raw, contaminated, or undercooked seafood should also be avoided due to the risk of contamination.18 during pregnancy, mothers are at a higher risk of contracting bacterial food poisoning, and the reaction might be more severe than if the mother wasn’t pregnant.18 undercooked meat, poultry, and eggs are foods that can carry bacteria that can affect the mother, and possibly the baby.18 unpasteurized foods can lead to foodborne illnesses. any low-fat products, such as low-fat milk or mozzarella, are healthy for the diet. raw milk, also known as unpasteurized milk, can contain bacteria such as campylobacter, e. coli, listeria, or salmonella. pregnant women are at higher risk of contracting these types of bacteria, and the reactions resulting from them will be more severe.19 these bacteria are also very common on unwashed fruits and vegetables and raw sprouts of any kind.18 the effects of caffeine and herbal teas on newborns are not clear, but doctors suspect they are negative. although caffeine can cross the placenta, the effects of it on newborns aren’t clear, so doctors recommend avoiding excess caffeine, just to be safe.17 there also is not much information on herbal teas and their effect on developing babies though doctors recommend that mother avoid these types of teas.18 despite this, there are specific herbal teas that encourage pregnant women to drink them.18 there is a mass amount of vitamins the baby needs to have a smooth development. for example, a significant lack of vitamin b may cause birth defects and stillbirth. calcium during pregnancy can significantly decrease the risk of contracting preeclampsia, a disease that causes a sudden increase in blood pressure.17 calcium also builds up the newborn’s bones and teeth. a significant lack of calcium can cause the baby’s bones to be brittle and can increase the risk of fractures and broken bones. vitamin d helps the calcium in the body to build up the newborn’s bones and teeth.17 a balanced diet is important for both the mother and the newborn. if one element or vitamin overweighs the others, many defects and problems can occur. a stabilized diet will provide the baby with optimal nutrition and condition for the developmental process to go smoothly and without any setbacks or problems.18 viruses the environment of the fetal development holds great significance in the development of the infant during pregnancy, more so when it includes viral infections in the mother’s body which will inevitably affect the outcome of the pregnancy.20 pathogens that contribute to neurodevelopmental disorders include the rubella virus, herpes simplex virus, influenza a virus, and cmv. studies have shown that infections that present during a mother’s pregnancy; sinusitis, pneumonia, pyelonephritis, or bacterial venereal disease, are linked to increasing the child’s neurodevelopmental risk by 2 times. this can be very extremely dangerous for the infant as it will elevate the risk of asd, which is a main portion of illnesses that are discovered.21 the danger lies in the possible long-term effects such as congenital anomalies or in some cases, death. the world health organization (who) has stated that of the 5,000,000 neonatal deaths that occur worldwide per year, approximately 2,000,000 are directly the result of infection.22 influence of environment during a woman’s pregnancy, it is crucial that she is in a safe environment. many small little things can affect the pregnancy, ultimately affecting the fetus's development as well, if the mother is exposed to certain things. domestic violence for pregnant women between the ages of 18-60 negatively affects obstetric-related outcomes as well as mental health during the postnatal period.23 exposure to violence during the woman’s pregnancy can lead to consequences such as hemorrhage, preterm rupture of membranes, recurrent miscarriages, premature placental abruption, and low birth weight.23 both the baby's growth and the postpartum period may be seriously harmed by this. during pregnancy, it's crucial that the woman is in a secure setting. if the mother is not in a safe environment and experiencing domestic violence it can lead to factors of stress, depression, or suicidal tendencies. depression is the most common causing the mother to lose interest in daily activity, ultimately affecting the fetus as well.24 one most seen types of depression during pregnancy special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.80 dhr proceedings ǀ http://dhrproceedings.org 10 2023, vol. 2 no. s2 7-14 is perinatal depression. this can leave the mother in a depressed state, which eventually leads to future health issues. if left untreated it can pose maternal risks such as preeclampsia, placental abruption, cesarean delivery, preterm admission, and maternal postpartum readmission.24 long-term neurodevelopmental consequences in offspring can also be presented during pregnancy if perinatal depression is not treated right away.24 pregnancy nutrition is important because it provides the fetus with the nutrients it needs for maturation into a healthy child. the fetus would also be adversely affected if the mother was not getting adequate nourishment. one major part of pregnancy is that the fetus is totally dependent on the mother’s vitamin status.25 vitamin d is critical for bone and calcium homeostasis as well as preventing neonatal hypocalcemia and preeclampsia.25 studies show that vitamin d deficiency is associated with postpartum depression which is why the status of vitamins is important in brain development, cognitive function, fetal bone growth, and neonatal lung maturation.25 during stages of the woman’s pregnancy, there can be complications along the way but it is crucial that she remains in a safe environment as it can show to have an effect on fetal development. during pregnancy, a variety of circumstances may arise, but the mother’s decision to remain in a healthy environment is paramount for the mother and developing child. genetics: age, interbreeding birth defects are mainly caused by malformations in the genetic composition of a fetus and are usually shown during the early stages of pregnancy, usually by the end of the first trimester.26 some of these malformations are influenced by the mother’s medical conditions, mutations in the genes, chromosomal abnormalities, single-gene defects, and dominant traits.27 chromosome abnormalities occur during the formation of reproductive cells or during early fetal development. these errors usually occur during the cell division process (meiosis and mitosis) when there are problems with the duplication and deletion of chromosomes. aside from numerical abnormalities in chromosomes, there are also structural changes in chromosomes that can lead to birth defects.27 chromosomes come in pairs, so the number becomes imbalanced when there is a missing chromosome (monosomy) or when there is an extra chromosome (trisomy).28 fetuses that suffer from trisomy often lead to miscarriage, but those who survive are diagnosed with moderate to severe birth defects.28 this is commonly seen in down syndrome patients who have an extra copy of chromosome 21, also known as trisomy 21. studies have shown that this abnormality usually originates from the mother due to age.29 other medical conditions that are caused by chromosomal deletion include heart defects, palatal abnormalities, learning difficulties, facial deformities, and psychiatric disorders in older patients like schizophrenia and bipolar disorder.30 balanced translocations do not alter the number of chromosomes, but they alter the structure of a chromosome, affecting the pairing system.28 carriers of this translocation are not affected by it, but they can experience difficulty reproducing. mothers can suffer miscarriages or in case of survival, the fetuses are at high risk of birth defects and other abnormalities.31 in the case of a family, two of three daughters suffered from intellectual and physical disabilities because they only inherited half of the mother’s abnormal chromosomes and half of the father’s normal chromosomes.28 because they did not inherit the two abnormal chromosomes from the mother, they were not chromosomally balanced, leading to birth defects. if there is no presence of numerical or structural chromosome abnormalities, genetic mutations are another cause of birth defects. the most common mutations in genes include sickle-cell anemia, cystic fibrosis, tay-sachs disease, and alzheimer’s.32 recurring symptoms from patients with these mutations are frequent infections, respiratory complications, organ damage, loss of motor skills, and seizures, among others.33 genetic mutations take place during cell division when there is a mistake in replacing, removing, or adding codes that are not readable by the cells.32 germline mutations happen in the parent’s reproductive cells and affect all the baby’s cells, making the mutation hereditary. somatic mutation occurs during the developing stage of the fetus and affects all the cells.32 it is commonly known that by the age of 40, a woman's chances of conceiving a pregnancy substantially diminish by 95%.34 in contrast, a healthy 20-year-old typically has full capabilities to get pregnant and that makes their chances of conceiving higher.35 naturally, when the body gets older, the production of eggs decreases substantially. this, however, is not the only thing to consider when attempting to develop a baby around the age of 40. the chances of a miscarriage will also increase around this age due to the progressive negative chromosomal changes in eggs or oocytes.36 physicians have the special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.80 dhr proceedings ǀ http://dhrproceedings.org 11 2023, vol. 2 no. s2 7-14 ability to make tests of the ovarian reserve to determine the best way to go about the pregnancy or to advise individuals who want to go through pregnancy at that age. inbreeding causes the effect of overlapping dna that results from the procreating of closely related biological partners that are related to the same common ancestors.34 the excess amount of dna typically is the cause of the permanent development of medical issues in the very early stages of fetus development. the chances of the infant being born with autosomal recessive disorders like cystic fibrosis or sickle cell anemia are usually in response to the increased chances of both parents carrying the recessive genes that cause these diseases.35 historically, royal families were commonly known to inbreed in their families to keep their blood “pure” by having consanguineous marriages.36 this has been shown to have the outcome of many body deformities one of which is known as the habsburg jaw. this facial deformity was present in the royal family of the habsburgs who ruled germany and austria. the facial deformity was a result of a recessive pattern from the biological parents. complications during labor as a mother starts to go into labor, there are many factors that can delay the birth of the infant. while in labor, the women are getting continuous check-ups to make sure their blood pressure, glucose, and temperature is going smoothly and they are dilating properly. some women may experience complications during their labor. for instance, pre-eclampsia is a serious condition that occurs to the mother usually after the 20-week mark or even after birth that affects the blood pressure and other vital organs such as the kidneys provoking them to not function correctly. some symptoms are present such as persistent headaches, trouble breathing, severe nausea, and changes in vision. this condition affects 5 to 8 percent of pregnancies and may even cause death.37 during labor, there are complications that occur such as the dilation process, amniotic fluid, and hemorrhaging. there can be complications with the dilation process, such as a prolonged latent phase, an arrest of dilation, or even precipitated dilation.38 others may experience the lack of being able to contract while in labor, prolonging labor delivery.38 while the infant is in the womb, it must change its position to where its head is facing down towards the cervix, but at times, babies are in fetal malposition, making it difficult for the mother to push. the amniotic fluid plays an important role for the fetus because it is a liquid that revolves around the fetus that protects it from harm. the mother may lack or have too much of the amniotic fluid which is called oligohydramnios and or polyhydramnios.37 although there are many more complications that can occur during labor, all of them can affect the infant and the mother causing them to be in critical conditions or even death. childbirth is taken with great precaution because things can take a turn quickly whether that be the birth moving quickly causing a dry birth to the birth going slowly to where the fetus excretes inside the mother. conclusion it is asserted that detecting certain defects early on in the pregnancy during the baby’s development would allow families to subject what care they would bring for the children. learning the negative factors and maternal behaviors that cause birth defects can increase healthier baby development. what negative factors and maternal behaviors affect fetal development? a conclusion of certain circumstances that would negatively affect fetal development would be maternal negative behaviors such as alcohol, drugs, smoking, and diet, while negative factors are viruses, the influence of environment, genetics, age, and complications during pregnancy and labor. consuming alcohol during pregnancy develops fasd early on and consumption can affect child stunt growth. if a mother is to consume most types of drugs they are risking the possibility of labor miscarriages, premature delivery, cognitive developmental problems, abnormal brain structure, and fetal stress.10 as previously stated, an aog study concluded that smoking during pregnancy opens up the risk for bone fracture, asthma, and child respiratory infections. in a case where a mother would inject drugs through needles, there is a high risk of obtaining hiv. it is confirmed that if the maternal mother does get hiv, the possibility of the infection being passed down to children is extremely high.12 a healthy diet is extremely vital in order to provide a steady pregnancy. in contrast to a healthy diet, a poor diet can increase anemia, preeclampsia, child stillborn, and the nervous system.16 including healthy meal plans and all nutrients is crucial because it strengthens infants' bones and teeth.18 viruses have also been a huge factor that may dictate negative fetal development. as described before, viruses have increased a child's special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.80 dhr proceedings ǀ http://dhrproceedings.org 12 2023, vol. 2 no. s2 7-14 neurodevelopment by twice as much, as well as elevating the risk of asd.21 congenital anomalies and death have resulted in infants from viral infections.29 in order for a pregnancy to run smoothly, a safe environment must be provided. in a violent situation, a pregnancy can negatively result in hemorrhage, preterm rupture of membranes, premature placental abruption, and low birth rate.23 although a safe environment is provided throughout the entire term, when the time comes to deliver the baby, it is crucial that the birth runs as smoothly as possible. not doing so, can result in a critical condition or death in the mother or the infant. genetically, occurrences like down syndrome, heart defects, and palatal abnormalities have resulted. providing accurate care and consideration for the mother and infant can reduce the risk of congenital defects. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. national library of medicine. (n.d.-a). birth defects. retrieved from https://medlineplus.gov/birthdefects.html 2. birth defects are common, costly, and critical | cdc. (2022, january 21). retrieved from https://www.cdc.gov/ncbddd/birthdefects/inf ographic.html 3. data & statistics on birth defects | cdc. (2022b, december 21). retrieved from https://www.cdc.gov/ncbddd/birthdefects/da ta.html 4. young, j. k., giesbrecht, h. e., eskin, m. n., aliani, m., & suh, m. (2014). nutrition implications for fetal alcohol spectrum disorder. advances in nutrition (bethesda, md.), 5(6), 675–692. https://doi.org/10.3945/an.113.004846 5. paley, b., & o'connor, m. j. (2011). behavioral interventions for children and adolescents with fetal alcohol spectrum disorders. alcohol research & health : the journal of the national institute on alcohol abuse and alcoholism, 34(1), 64–75. 6. fetal alcohol effects: behavior and learning problems. (n.d.). https://wa.kaiserpermanente.org/kbase/topic. jhtml?docid=tj5086 7. fetal alcohol exposure | national institute on alcohol abuse and alcoholism (niaaa). (n.d.). https://www.niaaa.nih.gov/publications/broc hures-and-fact-sheets/fetal-alcoholexposure#:~:text=about%2020%20to%203 0%20 percent,typically%20during%20the%20first %20 trimester.&text=more%20than%208%20 percent%20 of,typically%20during%20the%20first%20 trimester 8. kelly sj, day n, streissguth ap. effects of prenatal alcohol exposure on social behavior in humans and other species. neurotoxicol teratol. 2000 mar-apr;22(2):143-9. doi: 10.1016/s0892-0362(99)00073-2. pmid: 10758343; pmcid: pmc2699590. 9. price, h. r., collier, a. c., & wright, t. e. (2018). screening pregnant women and their neonates for illicit drug use: consideration of the integrated technical, medical, ethical, legal, and social issues. frontiers in pharmacology, 9. https://doi.org/10.3389/fphar.2018.00961 10. marchand, g. j., masoud, a. t., govindan, m., ware, k., king, a., ruther, s., . . . sainz, k. (2022). birth outcomes of neonates exposed to marijuana in utero. jama network open, 5(1), e2145653. https://doi.org/10.1001/jamanetworkopen.20 21.45653 11. forray, a. (2016d). substance use during pregnancy. f1000research, 5, 887. https://doi.org/10.12688/f1000research.7645 .1 12. effects of drug use during pregnancy | florida department of health. (n.d.). https://www.floridahealth.gov/programsand-services/prevention/substanceabuse/substance-abuse-duringpregnancy/index.html#:~:text=illicit%20dru g%20use%20during%20pregnancy,and%20 cognitive%20and%20behavioral%20proble ms special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.80 dhr proceedings ǀ http://dhrproceedings.org 13 2023, vol. 2 no. s2 7-14 13. neonatal abstinence syndrome and opioid use disorder | florida department of health. (n.d.). https://www.floridahealth.gov/diseases-andconditions/neonatal-abstinencesyndrome/index.html 14. neonatal abstinence syndrome (nas). (n.d.-b). march of dimes. https://www.marchofdimes.org/findsupport/topics/planning-baby/neonatalabstinence-syndrome-nas 15. tobacco and nicotine cessation during pregnancy: acog committee opinion, number 807. (2020). obstetrics and gynecology, 135(5), e221–e229. https://doi.org/10.1097/aog.000000000000 3822 16. maternal nutrition. (n.d.). unicef. https://www.unicef.org/nutrition/maternal#: ~:text=during%20pregnancy%2c%20poor %20diets%20lacking,and%20developmental %20delays%20for%20children 17. national library of medicine. (n.d.). pregnancy and nutrition. https://medlineplus.gov/pregnancyandnutriti on.html 18. pregnancy nutrition: foods to avoid during pregnancy. (2023, may 31). mayo clinic. https://www.mayoclinic.org/healthylifestyle/pregnancy-week-by-week/indepth/pregnancy-nutrition/art-20043844 19. assistant secretary for public affairs (aspa). (2020). people at risk: pregnant women. foodsafety.gov. https://www.foodsafety.gov/people-atrisk/pregnant-women#:~:text=raw%20 milk%2c%20 also%20 called%20 unpasteurized,and%20malik%20 products%2c%20 including%20 cheese 20. elgueta, d., murgas, p., riquelme, e., yang, g., & cancino, g. i. (2022). consequences of viral infection and cytokine production during pregnancy on brain development in offspring. frontiers in immunology, 13. https://doi.org/10.3389/fimmu.2022.816619 21. jash, s., & sharma, s. (2022). pathogenic infections during pregnancy and the consequences for fetal brain development. pathogens (basel, switzerland), 11(2), 193. https://doi.org/10.3390/pathogens11020193 22. goldenberg, r. l., culhane, j. f., & johnson, d. c. (2005). maternal infection and adverse fetal and neonatal outcomes. clinics in perinatology, 32(3), 523–559. https://doi.org/10.1016/j.clp.2005.04.006 23. semahegn, a., & mengistie, b. (2015). domestic violence against women and associated factors in ethiopia; systematic review. reproductive health, 12, 78. https://doi.org/10.1186/s12978-015-0072-1 24. miller, e. s., saade, g. r., simhan, h. n., monk, c., haas, d. m., silver, r. m., mercer, b. m., parry, s., wing, d. a., reddy, u. m., & grobman, w. a. (2022). trajectories of antenatal depression and adverse pregnancy outcomes. american journal of obstetrics and gynecology, 226(1), 108.e1–108.e9. https://doi.org/10.1016/j.ajog.2021.07.007 25. pilz, s., zittermann, a., obeid, r., hahn, a., pludowski, p., trummer, c., lerchbaum, e., pérez-lópez, f. r., karras, s. n., & märz, w. (2018). the role of vitamin d in fertility and during pregnancy and lactation: a review of clinical data. international journal of environmental research and public health, 15(10), 2241. https://doi.org/10.3390/ijerph15102241 26. what are birth defects? | cdc. (2021, november 5). centers for disease control and prevention. https://www.cdc.gov/ncbddd/birthdefects/fa cts.html#:~:text=birth%20 defects%20are%20 structural%20 changes,vary%20from%20mild%20to%20se rver 27. queremel milani da, tadi p. genetics, chromosome abnormalities. [updated 2023 apr 24]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2023 jan. available from: https://www.ncbi.nlm.nih.gov/books/nbk5 57691/ 28. worton r. g. (1977). chromosome abnormalities: a major cause of birth defects, stillbirth and spontaneous abortion. canadian medical association journal, 117(8), 849–51. 29. hultén, m., patel, s., westgren, m., papadogiannakis, n., jonsson, a., jonasson, j. g., & iwarsson, e. (2010). on the paternal origin of trisomy 21 down syndrome. molecular cytogenetics, 3(1), 4. https://doi.org/10.1186/1755-8166-3-4 30. prescott, k. r., & wilkie, a. o. (2007). genetic aspects of birth defects: new understandings of old problems. archives of disease in childhood. fetal and neonatal edition, 92(4), f308–f314. https://doi.org/10.1136/adc.2004.062968 31. trunca, c., mendell, n. r., & schilit, s. l. p. (2022). reproductive risk estimation calculator for balanced translocation special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.80 dhr proceedings ǀ http://dhrproceedings.org 14 2023, vol. 2 no. s2 7-14 carriers. current protocols, 2(12). https://doi.org/10.1002/cpz1.633 32. professional, c. c. m. (n.d.). genetic mutations in humans. cleveland clinic. https://my.clevelandclinic.org/health/body/2 3095-genetic-mutations-in-humans 33. thomas, j. (2019, november 28). most common genetic disorders. sonas home health care. https://www.sonashomehealth.com/mostcommon-genetic-disorders/ 34. saccone, g., gragnano, e., ilardi, b., marrone, v., strina, i., venturella, r., berghella, v., & zullo, f. (2022). maternal and perinatal complications according to maternal age: a systematic review and metaanalysis. international journal of gynecology and obstetrics: the official organ of the international federation of gynaecology and obstetrics, 159(1), 43–55. https://doi.org/10.1002/ijgo.14100 35. facog, s. b. m., & facog, s. b. m. (2023). getting pregnant at 40: faqs and tips for optimizing your fertility health. virginia physicians for women. https://vpfw.com/blog/getting-pregnant-at40-faqs-and-tips-for-optimizing-yourfertilityhealth/#:~:text=fertility%20specialists%20q uote%20approximately%20a,chance%20of %20experiencing%20healthy%20pregnancie s 36. female age and miscarriage spontaneous abortion. (n.d.). advanced fertility center of chicago. https://advancedfertility.com/patienteducation/causes-of-infertility/age-andfertility/#:~:text=the%20main%20 reason%20for%20the,abnormal%20 karyotype 37. preeclampsia. (n.d.). march of dimes. https://www.marchofdimes.org/findsupport/topics/pregnancy/preeclampsia 38. 38. cohen, w. r., & friedman, e. a. (2020). clinical evaluation of labor: an evidenceand experience-based approach. journal of perinatal medicine, 49(3), 241– 253. https://doi.org/10.1515/jpm-2020-0256 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 51 2023, vol. 2 no. s2 51-60 commentary substance use disorder in young adults across the united states shreya patel1,2, isabella garcia1,3, anahi bernal1,3, stephany tapia1,4, daniel martinez1,4, jocelin hernandez1,4, eric molina1,4, abril acevedo1,4, gabriel martinez1,5, christian zuniga1,6 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 south texas isd health professions, mercedes, tx 3 academy of health science professions & stem, la joya, tx 4 juarez lincoln high school, mission, tx 5 mcallen high school, mcallen, tx 6 la villa early college high school, la villa, tx received: august 3, 2023 accepted for publication: november 3, 2023 published: november 16, 2023 introduction more than any other age group in the united states, 32% of young adults between the ages of 1825 participate in frequent alcoholic misuse; with 22% further taking part in the abuse of illegal drugs.1 taking into consideration the rather vulnerable mind of young adults, they become more susceptible to risky behaviors that may lead to chronic long-term effects of irresponsible substance usage later on in their life.2 substance abuse disorder (sud) is a neuropsychiatric disorder that is described by a continuing desire to take drugs or partake in alcohol consumption despite its potential harmful consumption.3 although the majority of youth who partake in the use of substances do not reach problematic usage levels, 15% of young adults meet the criteria for sud.4 many young adults already have childhood risk factors, and the added stress from adulthood places these individuals at risk for misusing substances. employment difficulties, lack of a positive parent role model, and academic stress can also increase the risk of young adults misusing substances.5,6 sud however is a mental illness, and should be treated as any other chronic physical illnesses would be treated.7,8 alcohol use disorder alcohol use disorder is a chronic health condition where individuals struggle to manage their alcohol consumption, without considering the detrimental impact on their social, mental, and physiological health. if not treated it may lead to alcohol abuse, where serious consequences result from repeated excessive drinking, or alcohol dependence, where the individual has no control over their drinking behaviors. with over 100 million people suffering from alcohol use disorder (aud) in 2016, aud continues to be a global public health concern, in which there were over 15 million reported cases in the us since 2018 according to the national survey on drug use and health (nsduh).9 when compared to older individuals, young adults (ages 18 to 25) are more prone to engage in heavy episodic drinking and a variety of harmful alcohol-related activities, such as drunk driving. it is even estimated that excessive alcohol intake in the united states contributes to over 79,000 fatalities annually, especially among young adults.10 effects of aud on mental and social health the majority of substance use disorders have substantial correlations with separate mood and anxiety disorders. with depressive type disorders special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 52 2023, vol. 2 no. s2 51-60 being the most common of the psychological symptoms to coexist with aud, disruptive/irritable moods, feelings of worthlessness, and negative temperament are highly present amongst patients. these types of psychiatric disorders that affect the mood significantly have been 3.7 times more likely to be found as a result from extreme alcohol use and/or dependancy.11 it should be noted, however, that these symptoms can also very well be the causes for aud. additionally, riskier, irritable, and impulsive behavior can result from alcohol misuse as one may become more careless from episodic drinking, even to go as far as inflicting self-harm.12 alongside the mental effects that alcohol has on an individual, there are also social effects that affect both the individual and his/her relationships with others. social interactions related to alcohol consumption often involve negative interpersonal exchanges and failure to meet commitments pertaining to relationships. many alcohol related health problems affect others in addition to the drinker.13 harm to relatives, harm to family members, a negative impact on work and education, public order, and driving accidents are some of the many social effects that alcohol consumption has on the drinker’s society.14 effects of aud on physiological health the impact of alcohol use disorders (aud) on the physiological well-being of individuals presents a need for understanding of its detrimental effects on many bodily systems. from the moment a user takes their first sip, their body, especially the bloodstream, is intoxicated leading to short and long-term failures throughout the physiological structure of the human body. the consequences of excessive consumption goes far beyond immediate effects such as to what is known as a mere hangover. alcohol leads to life threatening health conditions including deficiency in all body systems. the effects of alcohol to the body depends on the blood alcohol concentration (bac). bac is the percent of ethyl alcohol or ethanol in an individual's bloodstream.15 the bac levels will vary depending on the number of alcoholic drinks, the time in which drinks are consumed, body weight, water composition, enzyme production and levels, sex assigned at birth, medication influences, and whether any food has been consumed.16 bac can be measured by breath, blood, or urine tests. the percentages range from 0% (no alcohol) to over 0.4% (possibly fatal).16 at 0.10% bac, individuals may experience a further reduction in reaction time, along with slurred speech and slowed thinking, heightening the dangers of tasks like driving or operating machinery.16 within the range of 0.15% to 0.30% bac, confusion, vomiting, and drowsiness become more pronounced, signaling a higher level of impairment and vulnerability. beyond 0.30% to 0.40% bac, the risk of alcohol poisoning escalates significantly, potentially leading to life-threatening conditions. individuals may lose consciousness, calling for immediate medical attention.17 when bac surpasses 0.40%, it reaches a potentially fatal level, putting individuals at risk of coma and respiratory arrest, a critical situation where breathing stops.17 aside from these short term effects, alcohol use disorders in young adults aging 18 to 25 leads to long-term impairments since their bodies are still in crucial stages of development and maturation. however, the progression of most effects are diagnosed either months or years of misusing alcohol. an aud significantly impacts the cardiovascular system which can include hypertension, tachycardia, and increasing the risk of heart disease, and stroke.18 it has been found that excessive alcohol consumption raises the blood pressure in several ways. it can directly stimulate the nervous system, increasing the sympathetic nervous system activity, which causes blood vessels to constrict or to become narrow.19 this narrowing causes a resistance to blood flow, consequently increasing blood pressure. in addition, it can also reduce the veins and arteries elasticity leading to hypertension.20 this is known as atherosclerosis. a risk of stroke is highered when the heart is exposed to blood clots; these clots are formed by excessive alcohol intake. ethanol is rapidly and almost completely absorbed in the digestive tract, mainly the small intestine, and then metabolized in the liver, primarily converting into acetaldehyde, a toxic compound responsible for some of the detrimental effects of alcohol on the body, including steatosis, or fatty liver, alcoholic hepatitis, and liver cirrhosis, which can further complicate into liver cancer.21 moreover, alcohol has the ability to disturb the natural hormonal regulation responsible for controlling kidney function. continuous and excessive alcohol consumption can lead to liver disease, which compounds the negative impact on the kidneys, causing problems in managing sodium and fluids and potentially leading to acute kidney failure.22 pancreatitis occurs from excessive alcohol consumption due to alcohol-induced inflammation and damage to the pancreas. chronic alcohol use can lead to the activation of digestive enzymes within the pancreas, causing inflammation and potentially leading to pancreatitis. alcohol use disorder can negatively impact brain development in young adults aged 18-25 due to the ongoing maturation of the brain special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 53 2023, vol. 2 no. s2 51-60 during this stage. excessive alcohol consumption disrupts the normal processes of brain development, affecting crucial functions such as learning, memory, decision-making, and emotional regulation. understanding the physiological impacts of alcohol use disorder in young adults in the us is crucial for developing targeted interventions and fostering a healthier future for this vulnerable population. prevalence of aud with regard to mental health and alcohol use problems, a significant amount of evidence exists which indicates that outcomes differ by both sex and race/ethnicity. approximately 21% of males and 13% of women experience binge drinking.23 men have been proven to consume more alcohol than women, drinking at least five times each month on average with 25% of them having at least nine drinks each time.23 overall, 9% of adult women and 13% of adult men reported having an alcohol drinking disorder in 2020.23 the prevalence of alcohol use disorders (aud) varies across racial/ethnic groups, however, it is suggested that ethnic minorities may face higher rates of addiction than national averages due to poor living conditions; limited access to specialized care; and elevated social, economic, emotional, and environmental risk factors.24 it has often been shown that native americans are especially vulnerable to the negative health consequences of alcohol. however, given their small size in relation to other racial groups (2.9% of the total u.s. population), native americans' influence on alcohol-related health effects on the u.s. population as a whole is less clear.25 in addition, it is important to take into consideration other contexts of alcohol use, such as, social, political, and economic variables. race/ethnicity alcoholism/ aud race/ ethnicity american indians and alaska natives 14.9% 27.6% caucasian 11.3% 17.0% asian american, native hawaiian, and other pacific islander 4.6% 8.0% hispanic or latino 8.4% 15.7% african american 7.4% 17.2% figure 1. the average percentage of alcoholism/aud compared to overall substance abuse among various racial and ethnic groups from the years 2016-202126,27 marijuana use disorder the prevalence of marijuana has increased substantially in the united states over the past decade, making cannabis one of the most used illicit drugs in the us.28 furthermore, this increase was aided dramatically due to the recent legalization of weed in various states across the us. the effects of cannabis on american society become more prevalent year after year; these effects include a drastic change in mental and social health among users. effects of marijuana use on mental and social health marijuana use disorder takes a huge toll on one's mental and social health. marijuana use can significantly affect social interactions and behavior towards others due to various factors. the drug's influence on verbal and nonverbal communication skills can result in difficulties expressing oneself clearly and accurately interpreting others' cues, leading to misunderstandings and reduced empathy.29 excessive marijuana use may lead to social withdrawal, as individuals prioritize drug use over engaging in social activities, straining relationships and limiting opportunities for interaction.29 the altered perception and behavior induced by marijuana can make users appear emotionally detached, impacting the dynamics of interpersonal relationships.29 frequent use of marijuana on young adults causes mental health effects, most of them being mood disorders, respiratory, depression, and anxiety.30 marijuana use disorder in young adults can have significant effects on the developing brain, as their brains are still undergoing crucial neurodevelopmental processes.31 the active compound in marijuana, tetrahydrocannabinol (thc), binds to cannabinoid receptors in the brain, disrupting the endocannabinoid system's normal functioning.31 this leads to an altered brain structure, impaired brain maturation, and dependency on marijuana.31 effects of marijuana use on physiological health the excessive use of marjuana can have notable effects on the physiological well-being. smoking marijuana can harm lung tissues, leading to potential scarring and respiratory problems, such as lung cancer. furthermore, marijuana use can cause rapid changes in heart rate and diastolic blood pressure, as well as physical effects like red eyes, dry mouth and throat, increased appetite, and widening of blood vessels.32 while some users may experience special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 54 2023, vol. 2 no. s2 51-60 feelings of relaxation and euphoria, others may encounter negative psychological effects. marijuana use can lead to disorientation, anxiety, and paranoia, particularly in individuals who may be more susceptible to these reactions. in more severe cases, marijuana use has been linked to temporary psychosis, characterized by losing touch with reality, experiencing hallucinations, and having paranoid thoughts.33 long-term use may contribute to the development of disorders like schizophrenia, a serious mental illness characterized by distorted thoughts, emotions, and perceptions.34 intoxication from high doses of cannabis can induce temporary psychotic symptoms in most individuals, heightening the risk of psychological distress associated with heavy use. approximately 26% of americans aged 18 to 26, roughly 1 in 4 young adults, experience diagnosable mental disorders in any given year.35 depressive illnesses and anxiety disorders have a complex relationship with substance use, including marijuana.36 prevalence of mud the consumption of marijuana has been the most common illegal drug in the united states; 48.2 million people, or about 18% of americans, consume it.37 from 2000 through 2008, there was no significant change in the annual number of rate ingestions of marijuana in young adults across the united states. there has been a very increasing amount of young adults consuming marijuana. the proportion of young adults that reported marijuana use reached 43% in 2021,, a significant increase from 34%, five years ago (2016) and 29%, ten years ago (2011).38 according to another study, an estimated 3 in 10 young adults use marijuana.39 the national epidemiologic survey on alcohol and related conditions conducted a survey in 2012 and 2013 on marijuana use and dsm-iv marijuana use disorder. this survey interviewed 36,309 adults over the age of 18. results concluded that 9.52% of u.s. adults have used marijuana in the past year with a 2.9% of people having a diagnosis of dsm-iv marijuana use disorder. age examinations had shown young adults to be highest at risk for mud and males with the greater number of marijuana use and use disorder. the number of individuals using marijuana is predicted to continue to grow as well as the number of people being affected by the usage.40 race/ethnicity past-year marijuana use past-year marijuana use disorder caucasian 9.4% 2.7% african american 12.7% 4.6% native american 17.1% 5.5% asian 5.0% 1.3% hispanic 8.4% 2.8% figure 2. marijuana use and mud in different races/ethnicities in young adults in the united states. sex past-year marijuana use past-year marijuana use disorder male 12.3% 4.2% female 6.9% 1.7% figure 3. marijuana use and mud varied percentages in sex in young adults in the united states. opioid use disorder opioid use disorder is another growing health concern among young adults. oud is a chronic relapse disorder that can lead to significant lifethreatening effects on people worldwide, especially in the u.s.41,42 opioids represent a large class of drugs that derive from the opium poppy plant. heroin, fentanyl, pain relievers, and prescriptions such as oxycodone and morphine are all considered opioids and are frequently abused by millions around the world.43 these substances are highly addictive and contribute to a variety of mental health, social, and physiological disorders. the increasing popularity these drugs have been receiving causes young adults who are introduced to them more prone to being affected. even though it is medically used for pain relief and initially blocks the pain signals between the brain and the body, some may use it for the euphoric effect produced. the more it is abused over time, tolerance begins to develop in the individual which leads to continuous use risking overdose and death.43 between 2005 to 2006, the rate of opioid abuse in the united states increased 64% and experienced the emergence of a nationwide public health crisis . death rates increased in 2016 by 27% from 2015.44 the rate of opioid misuse is high in the u.s. and increasingly prevalent among young adults. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 55 2023, vol. 2 no. s2 51-60 effects of oud on mental and social health oud has substantial mental effects on young adults, leading to cognitive impairments such as deficiencies in attention and judgment, as well as emotion dysregulation characterized by increased depression, anxiety, and suicide rates.45 the prefrontal cortex in the brain is responsible for executive functions such as judgment and planning. individuals with addictive disorders such as oud have abnormalities in that area of the brain which causes a decrease in their judgment to control the amount of drugs consumed.45 the more drugs consumed, the more dependent the brain gets resulting in more problems related to attention and regular executive functions. many people who have opioid use disorder either have a co-existing mental health condition or develop one due to their oud.46 in some cases, opioids are used to cope with the symptoms of their mental illness leading to oud. depression and anxiety disorders are commonly found in oud patients who try to use the euphoric effects to relieve their symptoms.47 opioids are highly addictive by creating artificial endorphins. repeated usage alters the brain and causes the body to believe it is an essential component.45 the difficulty to break free from the addiction often leads to feelings of hopelessness and the belief that suicide is the only option. in 2017, more than 40% of suicide and overdose deaths involved opioids.48 mental abnormalities caused by oud lead to drastic changes of social patterns within the individual. increased habits of hermit-like state continue to arise due to higher rates of depressive and anxiety induced symptoms.47, 49 seclusion is often associated with lack of normal accountability found in regular social interactions.50 vital support from friends and family are omitted in times of hardship. a metaanalysis study conducted in the u.s. shows only 3 in5 of those with oud seek relief treatment (1 in5 in the first 12 months and 2 in5 during their lifetime).51 in scenarios of a user experiencing withdrawal, irritation and emotional irregularities prove evident with significant rates of self harm notable in oud patients (around 10/100).52, 53 effects of oud on physiological health analgesic opioids are notorious for being abused and may lead to vast amounts of physiological damage in the user. short-term effects immediately after ingestion include nausea, changes in heart rate and breathing, euphoric like feelings, and a sedated state.54 these are in response to an opioid connecting and inhibiting receptors relating to feeling pain.55 long term effects of abnormal opioid use include the aforementioned symptoms as well as hypogonadism, decreased bone health, decreased pain tolerance, nervous/ gastrointestinal discrepancies and in extreme cases, death. more than 47,000 individuals in the u.s. die annually).56-60 an individual with an oud can experience withdrawal when they try to stop their addiction and can experience increased sensations of muscle/skeletal ache, muscular spasms, cravings, skin irritation and constipation.61, 62 these symptoms are an important factor for the continued use of opioids. prevalence of oud in the us, the prevalence of oud in young adults continues to increase. the more accessible and popular the drugs become, the greater the rates of oud in young adults become. in order to monitor the prevalence of opioid misuse and use disorder, a national survey study was done in 2015 and 2016.63 this survey included 28,213 young adults which corresponded to an estimate of 69.5 million young adults. from a total number of 56,070 individuals, 32.2% of those were young adults who reportedly used prescription opioids, with an additional 7.8% reporting a misuse of prescription opioids or use disorder.63 along with age groups, this survey also obtained results on the prevalence of prescription opioid misuse in different races/ethnicities which is displayed on the table below. it can be seen that caucasians have the greatest percentage of reported oud followed by hispanics. race/ethnicity prescription opioid use disorder percentage prescription opioid misuse without disorder caucasian 3.2% 20.2% african american 1.9% 17.6% hispanic 3.0% 18.2% others 2.6% 17.8% figure 4. opioid use disorder and opioid misuse in young adults from different races/ethnicities in the united states from 2015 to 2016. conclusion the us food and drugs administration (fda) approved drugs for treatments of substance use disorder such as (buprenorphine,methadone, and naltrexone) to help people with their addiction.64 these relieve the withdrawal symptoms and special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 56 2023, vol. 2 no. s2 51-60 psychological craving that causes chemical imbalances in the body.65 however, treatments should be obligated for better improvements on mental health, such as counseling and behavioral therapies, and medications for these sud. acamprosate, naltrexone, and disulfiram, medications used by people in recovery, are proven to be very effective for preventing addiction and maintaining sobriety.65 there are no current medications approved by the fda for mud treatment.66 education about the usage, prevalence, as well as awareness of the biological effects of substance use were some of the most favored and promising strategies to reduce substance abuse in young adults.67 risk reduction techniques were also successful at changing behavior, in addition to hearing testimonies. other methods that have been beneficial in modifying behavior include taking part in programs that address sexual assault prevention, or learning about safety issues like drunk driving.67 although preventative initiatives have shown to be successful, families and other significant adults continue to have the greatest influence over how young adults handle drugs. it is essential to become involved early, before high school, to educate the next generation about addiction and substance use disorders. among the youth-focused preventive measures are programs that instruct parents on how to properly watch over, communicate with, and set and enforce family rules surrounding substance use.68, 69 since drug and alcohol abuse is a widespread issue that frequently begins among high school and college students, a variety of protective factors should be taken into account. the effective way for prevention of adolescent alcohol and other drugs is through a risk-focused approach, a prevention to know what decision has to be made.70 having strong beliefs against substance abuse, the desire to maintain one's health, high paternal awareness of drugs, school connectedness, structured activity and having strong religious beliefs.71 any positive change is progress to prevent substances from destroying someone's future. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. murphy jg, dennhardt aa. the behavioral economics of young adult substance abuse. prev med. 2016;92:24-30. doi:10.1016/j.ypmed.2016.04.022 2. lepine se, klemperer em, west jc, et al. exploring definitions of "addiction" in adolescents and young adults and correlation with substance use behaviors. int j environ res public health. 2022;19(13):8075. published 2022 jun 30. doi:10.3390/ijerph19138075 3. zou z, wang h, d'oleire uquillas f, wang x, ding j, chen h. definition of substance and non-substance addiction. adv exp med biol. 2017;1010:21-41. doi: 10.1007/978981-10-5562-1_2. pmid: 29098666. 4. squeglia lm, fadus mc, mcclure ea, tomko rl, gray km. pharmacological treatment of youth substance use disorders. j child adolesc psychopharmacol. 2019 aug;29(7):559-572. doi: 10.1089/cap.2019.0009. epub 2019 apr 22. pmid: 31009234; pmcid: pmc6727439. 5. santa maria dm, narendorf sc, cross mb. prevalence and correlates of substance use in homeless youth and young adults. j addict nurs. 2018 jan/mar;29(1):23-31. doi: 10.1097/jan.0000000000000206. pmid: 29505458. 6. broman cl. the availability of substances in adolescence: influences in emerging adulthood. j child adolesc subst abuse. 2016;25(5):487-495. doi: 10.1080/1067828x.2015.1103346. epub 2016 may 26. pmid: 29200806; pmcid: pmc5710832. 7. mclellan at, lewis dc, o'brien cp, kleber hd. drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. jama. 2000 oct 4;284(13):1689-95. doi: 10.1001/jama.284.13.1689. pmid: 11015800. 8. mclellan at, starrels jl, tai b, gordon aj, brown r, ghitza u, gourevitch m, stein j, oros m, horton t, lindblad r, mcneely j. can substance use disorders be managed special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 57 2023, vol. 2 no. s2 51-60 using the chronic care model? review and recommendations from a nida consensus group. public health rev. 2014 jan;35(2):http://www.journalindex.net/visit. php?j=6676. doi: 10.1007/bf03391707. pmid: 26568649; pmcid: pmc4643942. 9. alcover kc, lyons aj, oluwoye o, muse id, kelly me, mcdonell mg. onset of alcohol use disorder among alcohol initiates by race/ethnicity. alcohol. 2021;97:13-21. doi:10.1016/j.alcohol.2021.08.002 10. white am, hingson rw, pan ij, yi hy. hospitalizations for alcohol and drug overdoses in young adults ages 18-24 in the united states, 1999-2008: results from the nationwide inpatient sample. j stud alcohol drugs. 2011;72(5):774-786. doi:10.15288/jsad.2011.72.774 11. mchugh rk, weiss rd. alcohol use disorder and depressive disorders. alcohol res. 2019;40(1):arcr.v40.1.01. published 2019 jan 1. doi:10.35946/arcr.v40.1.01 12. grant bf, stinson fs, dawson da, et al. prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the national epidemiologic survey on alcohol and related conditions. arch gen psychiatry. 2004;61(8):807-816. doi:10.1001/archpsyc.61.8.807 13. room r, ferris j, laslett am, livingston m, mugavin j, wilkinson c. the drinker's effect on the social environment: a conceptual framework for studying alcohol's harm to others. int j environ res public health. 2010 apr;7(4):1855-71. doi: 10.3390/ijerph7041855. epub 2010 apr 21. pmid: 20617064; pmcid: pmc2872341. 14. room r, jernigan d, carlini cotrim b, gureje o, mäkelä k, marshall m, medinamora me, monteiro m, parry c, partanen j, riley l, saxena s. alcohol in developing societies: a public health approach. finnish foundation for alcohol studies; helsinki, finland: 2002 15. what is blood alcohol concentration (bac)? | vaden health services. vaden.stanford.edu. https://vaden.stanford.edu/super/education/al cohol-drug-info/reduce-your-risk/whatblood-alcohol-concentration-bac 16. blood alcohol content (bac): what it is & levels. cleveland clinic. https://my.clevelandclinic.org/health/diagno stics/22689-blood-alcohol-contentbac#:~:text=blood%20alcohol%20level%20 (bac)%2c 17. marketing communications: web // university of notre dame. blood alcohol concentration // rev. james e. mcdonald, c.s.c., center for student well-being // university of notre dame. rev. james e. mcdonald, c.s.c., center for student wellbeing. published 2019. https://mcwell.nd.edu/your-wellbeing/physical-well-being/alcohol/bloodalcohol-concentration/ 18. altura bm, altura bt. role of magnesium and calcium in alcohol-induced hypertension and strokes as probed by in vivo television microscopy, digital image microscopy, optical spectroscopy, 31p-nmr, spectroscopy and a unique magnesium ionselective electrode. alcohol clin exp res. 1994 oct;18(5):1057-68. doi: 10.1111/j.1530-0277.1994.tb00082.x. pmid: 7847586. 19. husain k, ansari ra, ferder l. alcoholinduced hypertension: mechanism and prevention. world j cardiol. 2014 may 26;6(5):245-52. doi: 10.4330/wjc.v6.i5.245. pmid: 24891935; pmcid: pmc4038773. 20. hwang cl, muchira j, hibner ba, phillips sa, piano mr. alcohol consumption: a new risk factor for arterial stiffness? cardiovasc toxicol. 2022 mar;22(3):236245. doi: 10.1007/s12012-022-09728-8. epub 2022 feb 23. pmid: 35195845; pmcid: pmc8863568. 21. paquot n. le métabolisme de l’alcool [the metabolism of alcohol]. rev med liege. 2019 may;74(5-6):265-267. french. pmid: 31206264. 22. epstein m. alcohol's impact on kidney function. alcohol health res world. 1997;21(1):84-92. pmid: 15706766; pmcid: pmc6826793. 23. excessive alcohol use and risks to men’s health. centers for disease control and prevention. october 31, 2022. accessed august 2, 2023. https://www.cdc.gov/alcohol/factsheets/menshealth.htm#:~:text=adult%20men%20drin k%20more%20than,with%2049%25%20of %20adult%20women.&amp;text=men%20a re%20more%20likely%20to%20binge%20d rink%20than%20women. 24. alcover kc, lyons aj, oluwoye o, muse id, kelly me, mcdonell mg. onset of alcohol use disorder among alcohol initiates https://mcwell.nd.edu/your-well-being/physical-well-being/alcohol/blood-alcohol-concentration/ https://mcwell.nd.edu/your-well-being/physical-well-being/alcohol/blood-alcohol-concentration/ https://mcwell.nd.edu/your-well-being/physical-well-being/alcohol/blood-alcohol-concentration/ special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 58 2023, vol. 2 no. s2 51-60 by race/ethnicity. alcohol. 2021;97:13-21. doi:10.1016/j.alcohol.2021.08.002 25. the national council on aging. ncoa.org. published january 10, 2023. https://ncoa.org/article/american-indiansand-alaska-natives-key-demographics-andcharacteristics 26. american addiction centers. how different cultures deal with alcoholism. alcohol.org. published january 19, 2023. https://alcohol.org/alcoholism-and-race/ 27. highlights for the 2021 national survey on drug use and health samhsa. accessed august 3, 2023. https://www.samhsa.gov/data/sites/default/fi les/202212/2021nsduhffrhighlightsre123022.p df. 28. cdc. data and statistics. cdc. published june 8, 2021. https://www.cdc.gov/marijuana/datastatistics.htm 29. ansell eb, laws hb, roche mj, sinha r. effects of marijuana use on impulsivity and hostility in daily life. drug alcohol depend. 2015 mar 1;148:136-42. doi: 10.1016/j.drugalcdep.2014.12.029. epub 2015 jan 6. pmid: 25595054; pmcid: pmc4330120. 30. mental health | health effects | marijuana | cdc. www.cdc.gov. published april 22, 2022. https://www.cdc.gov/marijuana/healtheffects/mentalhealth.html#:~:text=marijuana%20use%20h as%20also%20been 31. volkow nd, swanson jm, evins ae, delisi le, meier mh, gonzalez r, bloomfield ma, curran hv, baler r. effects of cannabis use on human behavior, including cognition, motivation, and psychosis: a review. jama psychiatry. 2016 mar;73(3):292-7. doi: 10.1001/jamapsychiatry.2015.3278. pmid: 26842658. 32. nida. 2021, april 19. what are marijuana's effects?. retrieved from https://nida.nih.gov/publications/researchreports/marijuana/what-are-marijuanaeffects 33. sharma p, murthy p, bharath mm. chemistry, metabolism, and toxicology of cannabis: clinical implications. iran j psychiatry. 2012 fall;7(4):149-56. pmid: 23408483; pmcid: pmc3570572. 34. national institute on drug abuse. is there a link between marijuana use and psychiatric disorders? national institute on drug abuse. published 2020. https://nida.nih.gov/publications/researchreports/marijuana/there-link-betweenmarijuana-use-psychiatric-disorders 35. hall w, degenhardt l. cannabis use and the risk of developing a psychotic disorder. world psychiatry. 2008;7(2):68-71. doi:https://doi.org/10.1002/j.20515545.2008.tb00158.x 36. john hopkins medicine. mental health disorder statistics. john hopkins medicine. published 2019. https://www.hopkinsmedicine.org/health/we llness-and-prevention/mental-healthdisorder-statistics 37. cdc. data and statistics. cdc. published june 8, 2021. https://www.cdc.gov/marijuana/datastatistics.htm 38. marijuana and hallucinogen use among young adults reached all-time high in 2021. national institutes of health (nih). published august 22, 2022. https://www.nih.gov/news-events/newsreleases/marijuana-hallucinogen-use-amongyoung-adults-reached-all-time-high-2021 39. centers for disease control and prevention. addiction | health effects | marijuana | cdc. www.cdc.gov. published september 9, 2021. https://www.cdc.gov/marijuana/healtheffects/addiction.html 40. hasin ds, saha td, kerridge bt, et al. prevalence of marijuana use disorders in the united states between 2001-2002 and 20122013. jama psychiatry. 2015;72(12):1235. doi:https://doi.org/10.1001/jamapsychiatry.2 015.1858 41. taylor jl, samet jh. opioid use disorder. ann intern med. 2022;175(1):itc1-itc16. doi:10.7326/aitc202201180 42. sharma b, bruner a, barnett g, fishman m. opioid use disorders. child adolesc psychiatr clin n am. 2016;25(3):473-487. doi:10.1016/j.chc.2016.03.002 43. opioid basics | cdc’s response to the opioid overdose epidemic | cdc. www.cdc.gov. published october 2, 2021. https://www.cdc.gov/opioids/basics/index.ht ml#:~:text=opioids%20are%20a%20class% 20of%20drugs%20used%20to%20reduce%2 0pain.&text=common%20types%20are%20 oxycodone%20(oxycontin 44. lyden j, binswanger ia. the united states opioid epidemic. seminars in perinatology. 2019;43(3):123-131. https://www.cdc.gov/marijuana/data-statistics.htm https://www.cdc.gov/marijuana/data-statistics.htm special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 59 2023, vol. 2 no. s2 51-60 doi:https://doi.org/10.1053/j.semperi.2019.0 1.001 45. kosten tr, george tp. the neurobiology of opioid dependence: implications for treatment. sci pract perspect. 2002;1(1):1320. doi:10.1151/spp021113 46. jones cm, mccance-katz ef. co-occurring substance use and mental disorders among adults with opioid use disorder. drug and alcohol dependence. 2019;197:78-82. doi:https://doi.org/10.1016/j.drugalcdep.201 8.12.030 47. sullivan md. depression effects on longterm prescription opioid use, abuse, and addiction. clin j pain. 2018;34(9):878-884. doi:10.1097/ajp.0000000000000603 48. bohnert asb, ilgen ma. understanding links among opioid use, overdose, and suicide. n engl j med. 2019;380(1):71-79. doi:10.1056/nejmra1802148 49. support ew and i. va.gov | veterans affairs. www.mirecc.va.gov. accessed august 3, 2023. https://www.mirecc.va.gov/suicidepreventio n/documents/cpdd2020_socialconnection_oud. 50. seppala de. connectedness & health: the science of social connection. the center for compassion and altruism research and education. published may 9, 2014. accessed august 3, 2023. https://ccare.stanford.edu/uncategorized/con nectedness-health-the-science-of-socialconnectioninfographic/#:~:text=people%20low%20in %20social%20connection 51. hall n, le l, majmudar i, teesson m, mihalopoulos c. treatment-seeking behavior among people with opioid use disorder in the high-income countries: a systematic review and meta-analysis. plos one. 2021 oct 15;16(10):e0258620. doi: 10.1371/journal.pone.0258620. pmid: 34653220; pmcid: pmc8519451. 52. piazza pv, deroche-gamonet v. a multistep general theory of transition to addiction. psychopharmacology (berl). 2013 oct;229(3):387-413. doi: 10.1007/s00213013-3224-4. epub 2013 aug 21. pmid: 23963530; pmcid: pmc3767888. 53. padmanathan p, forbes h, redaniel mt, gunnell d, lewer d, moran p, watson b, degenhardt l, hickman m. self-harm and suicide during and after opioid agonist treatment among primary care patients in england: a cohort study. lancet psychiatry. 2022 feb;9(2):151-159. doi: 10.1016/s22150366(21)00392-8. epub 2021 dec 15. pmid: 34921800. 54. volkow n, benveniste h, mclellan at. use and misuse of opioids in chronic pain. annu rev med. 2018 jan 29;69:451-465. doi: 10.1146/annurev-med-011817-044739. epub 2017 oct 13. pmid: 29029586. 55. ghelardini c, di cesare mannelli l, bianchi e. the pharmacological basis of opioids. clin cases miner bone metab. 2015 sepdec;12(3):219-21. doi: 10.11138/ccmbm/2015.12.3.219. epub 2015 dec 29. pmid: 26811699; pmcid: pmc4708964. 56. pergolizzi jv jr, raffa rb, rosenblatt mh. opioid withdrawal symptoms, a consequence of chronic opioid use and opioid use disorder: current understanding and approaches to management. j clin pharm ther. 2020 oct;45(5):892-903. doi: 10.1111/jcpt.13114. epub 2020 jan 27. pmid: 31986228. 57. study shows how morphine may contribute to bone loss and cancer-induced bone pain. uarizona health sciences. published july 5, 2023. accessed august 2, 2023. https://healthsciences.arizona.edu/newsroom /news-releases/0723/study-shows-howmorphine-may-contribute-bone-loss-andcancerinduced#:~:text=prior%20research%20in%2 0preclinical%20and 58. tabanelli r, brogi s, calderone v. targeting opioid receptors in addiction and drug withdrawal: where are we going? int j mol sci. 2023 june 29;24(13):10888. doi: 10.3390/ijms241310888. pmid: 37446064; pmcid: pmc10341731. 59. candiotti ka, gitlin mc. review of the effect of opioid-related side effects on the undertreatment of moderate to severe chronic non-cancer pain: tapentadol, a step toward a solution? curr med res opin. 2010 jul;26(7):1677-84. doi: 10.1185/03007995.2010.483941. pmid: 20465361. 60. strang j, volkow nd, degenhardt l, hickman m, johnson k, koob gf, marshall bdl, tyndall m, walsh sl. opioid use disorder. nat rev dis primers. 2020 jan 9;6(1):3. doi: 10.1038/s41572-019-0137-5. pmid: 31919349. 61. nida. prescription opioids drugfacts. national institute on drug abuse website. https://nida.nih.gov/publications/drugfacts/p special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.90 dhr proceedings ǀ http://dhrproceedings.org 60 2023, vol. 2 no. s2 51-60 rescription-opioids. june 1, 2021 accessed august 1, 2023. 62. mehta n, o'connell k, giambrone gp, baqai a, diwan s. efficacy of methylnaltrexone for the treatment of opioidinduced constipation: a meta-analysis and systematic review. postgrad med. 2016;128(3):282-9. doi: 10.1080/00325481.2016.1149017. epub 2016 feb 23. pmid: 26839023. 63. hudgins jd, porter jj, monuteaux mc, bourgeois ft. prescription opioid use and misuse among adolescents and young adults in the united states: a national survey study. plos med. 2019;16(11):e1002922. published 2019 nov 5. doi:10.1371/journal.pmed.1002922 64. harrison tk, kornfeld h, aggarwal ak, lembke a. perioperative considerations for the patient with opioid use disorder on buprenorphine, methadone, or naltrexone maintenance therapy. anesthesiol clin. 2018;36(3):345-359. doi:10.1016/j.anclin.2018.04.002 65. samhsa. medications, counseling, and related conditions. www.samhsa.gov. published march 22, 2023. https://www.samhsa.gov/medicationssubstance-use-disorders/medicationscounseling-related-conditions 66. nida. available treatments for marijuana use disorders. national institute on drug abuse website. https://nida.nih.gov/publications/researchreports/marijuana/available-treatmentsmarijuana-use-disorders. april 13, 2021 accessed august 3, 2023. 67. griffin kw, botvin gj. evidence-based interventions for preventing substance use disorders in adolescents. child and adolescent psychiatric clinics of north america. 2010;19(3):505-526. doi:https://doi.org/10.1016/j.chc.2010.03.00 5 68. moreland ad, lopez cm, gilmore ak, et al. substance use prevention programming for adolescents and young adults: a mixedmethod examination of substance use perceptions and use of prevention services [published correction appears in subst use misuse. 2021;56(1):174]. subst use misuse. 2020;55(14):2341-2347. doi:10.1080/10826084.2020.1817079 69. youth.gov. “prevention | youth.gov.” youth.gov, 2019, youth.gov/youthtopics/substance-abuse/evidence-basedprograms-youth-substance-abuseprevention-and-treatment. 70. samhsa. risk and protective factors.;2019:1. https://www.samhsa.gov/sites/default/files/2 0190718-samhsa-risk-protective-factors.pdf 71. nawi am, ismail r, ibrahim f, et al. risk and protective factors of drug abuse among adolescents: a systematic review. bmc public health. 2021;21(1):2088. published 2021 nov 13. doi:10.1186/s12889-02111906-2 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.4 dhr proceedings ǀ http://dhrproceedings.org 24 2024, vol. 4 no. s2 pg. 24-31 manuscript the bidirectional impact of irregular sleep patterns on cognitive function in adolescents aged 14–17: a developmental perspective marisol acosta1, daphne aldape1,2, gael garcia1,2, cruz ortiz1,3, michelle richaud1,3, alondra rodriguez1,2, helen rodriguez1,2, valeria segura1,3 1 dhr health high school and community outreach 2 south texas isd medical professions 3 south texas isd health professions received: july 3, 2024 accepted for publication: january 24, 2025 introduction adolescence, ages 10 to 19, is a period of significant biological, psychological, and social change.1 this developmental stage is characterized by a natural shift in circadian rhythms, leading to a later sleep-wake phase preference.2,3 however, societal demands, such as early school start times and extracurricular activities, often conflict with these biological changes, resulting in chronic sleep restriction.4 this sleep disruption has profound and bidirectional effects on cognitive function, impacting academic performance, emotional well-being, and overall health.4,5 this literature review examines the bidirectional relationship between irregular sleep patterns and cognitive function in adolescents aged 14–17, focusing on the interplay of biological, environmental, and psychosocial factors. biological factors influencing sleep and cognition during adolescence, hormonal changes associated with puberty significantly impact sleep architecture and timing.5,6 melatonin, a hormone regulating sleep-wake cycles, is delayed in adolescents, contributing to later sleep onset.4 this "sleep phase delay" is often exacerbated by increased exposure to artificial light from electronic devices and late-night social activities.7,8 furthermore, the developing brain undergoes significant structural and functional changes during this period, making it particularly vulnerable to the negative consequences of sleep deprivation.9 insufficient sleep has been linked to impaired prefrontal cortex (pfc) function, a brain region crucial for executive functions such as attention, working memory, and decision-making.9,10 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.4 dhr proceedings ǀ http://dhrproceedings.org 25 2024, vol. 4 no. s2 pg. 24-31 studies have shown that sleep restriction in adolescents leads to deficits in these cognitive domains.11,12 conversely, adequate sleep supports pfc development and optimal cognitive performance.9 the impact of sleep on brain regions involved in emotional processing is also substantial, with poor sleep quality linked to increased negative affect and reduced emotional regulation.10-13 the interplay between sleep and hormonal changes is complex and not fully understood. for example, while melatonin release is delayed during puberty, other hormones, such as cortisol and growth hormone, also affect sleep regulation.1 further research is needed to elucidate the precise mechanisms through which hormonal fluctuations interact with sleep and affect cognitive function. additionally, the impact of genetic factors on sleep patterns and their susceptibility to cognitive impairment requires further investigation.2 individual differences in sleep needs and responses to sleep deprivation are also not fully understood.14 environmental and psychological factors beyond biological factors, environmental and psychosocial factors significantly contribute to irregular sleep patterns and their impact on cognition. the widespread use of electronic devices, particularly smartphones and tablets, before bedtime disrupts sleep through the suppression of melatonin production and the stimulation of the nervous system.8,15 this increased screen time is frequently associated with later bedtimes and reduced sleep duration, leading to daytime sleepiness and impaired cognitive performance.3-4,16 furthermore, academic pressure, extracurricular activities, and social engagements can contribute to irregular sleep schedules and insufficient sleep.3,17 the pressure to succeed academically can lead to late-night studying, reducing sleep time and impacting cognitive function.4 similarly, social activities, such as socializing with peers or attending events, can extend bedtime and result in sleep debt. the influence of socioeconomic status (ses) on sleep patterns and cognitive outcomes is also worthy of note. children and adolescents from lower ses backgrounds often face environmental stressors such as noise pollution and overcrowding, which can negatively impact sleep quality.16 these stressors can further exacerbate the already increased risk of sleep disturbance among adolescents from minority groups.16,18 furthermore, access to healthcare and resources to address sleep problems may be limited for families with lower ses, potentially leading to untreated sleep disorders and their associated cognitive consequences. the interaction between environmental factors, psychosocial stress, and sleep-related problems needs further exploration, particularly considering the cumulative effect of these factors on cognitive development.8 bidirectional relationships: sleep and cognitive function the relationship between irregular sleep patterns and cognitive function in adolescents is bidirectional. sleep deprivation impairs cognitive function, as discussed previously. 11,12 however, pre-existing cognitive difficulties, such as those associated with neurodevelopmental disorders like attention-deficit/hyperactivity disorder (adhd), can also contribute to sleep problems. special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.4 dhr proceedings ǀ http://dhrproceedings.org 26 2024, vol. 4 no. s2 pg. 24-31 adolescents with adhd often experience difficulties with sleep initiation, maintenance, and consolidation.2,19 this disrupted sleep can further exacerbate adhd symptoms, creating a vicious cycle of impaired cognition and sleep disturbance. the bidirectional nature of this relationship is supported by studies showing that sleep problems are associated with increased risk of mental health issues such as depression and anxiety in adolescents, which can further disrupt sleep patterns.20-22 the impact of sleep problems on specific aspects of cognitive function has been extensively studied. executive functions, including attention, working memory, and inhibitory control, are particularly vulnerable to sleep deprivation.10-11 studies have demonstrated that sleep-restricted adolescents show impairments in tasks assessing these functions.12 moreover, sleep disturbances are associated with reduced academic performance, suggesting a direct link between sleep and cognitive skills needed for learning.4,5 the complex interplay between sleep and various aspects of cognitive function, particularly the impact on executive functions and academic performance, requires further study to fully understand the mechanisms involved. longitudinal studies are crucial to disentangle the causal relationships and identify potential intervention targets.20 the role of mental health mental health plays a significant role in the bidirectional relationship between sleep and cognition in adolescents. sleep problems are frequently comorbid with anxiety and depression, and these conditions can exacerbate each other.20-23 anxiety and depression can disrupt sleep through physiological mechanisms such as increased arousal and worry, leading to insomnia and poor sleep quality.23 conversely, sleep deprivation can worsen symptoms of anxiety and depression, potentially increasing the risk of self-harm and suicidal ideation.20-24 the impact of sleep disturbance on mental health is further complicated by the influence of social and environmental factors, such as peer victimization.25 exposure to bullying or other forms of peer victimization can significantly disrupt sleep and contribute to mental health problems, creating a cascade of negative effects on both sleep and cognition. studies have highlighted the need for further research to fully understand the complex interaction between sleep, mental health, and cognition in adolescents. longitudinal studies are needed to determine the causal relationships and identify effective interventions.20 it is important to consider the interplay of biological, environmental, and psychosocial factors when addressing sleep problems and their impact on mental health and cognitive function in adolescents. the bidirectional nature of these relationships highlights the importance of early intervention and treatment to mitigate long-term consequences. furthermore, the potential impact of specific sleep disorders, such as delayed sleep-wake phase disorder (dspsd), on both mental health and cognition warrants further investigation.2 the co-occurrence of dspsd with other neurodevelopmental and psychiatric disorders needs to be explored further to understand the potential mechanisms and develop effective treatment strategies. special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.4 dhr proceedings ǀ http://dhrproceedings.org 27 2024, vol. 4 no. s2 pg. 24-31 interventions and future directions given the significant impact of irregular sleep patterns on cognitive function and mental health in adolescents, the development and implementation of effective interventions are crucial. promoting healthy sleep hygiene practices, such as establishing a consistent bedtime routine, limiting screen time before bed, and creating a conducive sleep environment, is a primary intervention strategy.26 cognitive behavioral therapy for insomnia (cbt-i) has also shown promise in improving sleep quality and reducing daytime sleepiness in adolescents.19 this approach focuses on identifying and modifying maladaptive thoughts and behaviors that contribute to sleep problems. in addition to cbt-i, other interventions, such as chronotherapy (gradually shifting bedtime and wake time to align with the desired sleep schedule) and melatonin supplementation, may be beneficial for adolescents with specific sleep disorders.2 however, the efficacy of pharmacological interventions for sleep problems in adolescents requires further research.27 future research should focus on several key areas. large-scale longitudinal studies are needed to further elucidate the bidirectional relationship between sleep and cognition, considering the influence of various biological, environmental, and psychosocial factors.7 these studies should investigate the impact of specific sleep disorders on different cognitive domains and mental health outcomes. moreover, research should explore the effectiveness of different interventions in diverse adolescent populations, taking into account factors such as age, gender, ethnicity, and socioeconomic status.16 the development of culturally sensitive and accessible interventions is crucial to ensure equitable access to effective sleep care. finally, research should examine the long-term consequences of adolescent sleep disruption on cognitive function and mental health, highlighting the need for early intervention and prevention strategies.28 studies exploring the effectiveness of school-based interventions in promoting healthy sleep habits and addressing the societal pressures that contribute to sleep problems are also essential. conclusion irregular sleep patterns have a profound and bidirectional impact on cognitive function in adolescents aged 14–17. this relationship is influenced by a complex interplay of biological, environmental, and psychosocial factors. sleep deprivation impairs cognitive performance, particularly in executive functions and academic achievement, while pre-existing cognitive difficulties can contribute to sleep problems. furthermore, mental health conditions such as anxiety and depression are frequently comorbid with sleep disturbances, creating a vicious cycle of negative effects. effective interventions, including promoting healthy sleep hygiene and cbti, are crucial for improving sleep quality and mitigating the negative consequences of sleep disruption. future research should focus on large-scale longitudinal studies to further elucidate these complex relationships and develop culturally sensitive and accessible interventions to promote healthy sleep and optimal cognitive development in adolescents. the long-term consequences of adolescent sleep deprivation and the effectiveness of school-based interventions special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.4 dhr proceedings ǀ http://dhrproceedings.org 28 2024, vol. 4 no. s2 pg. 24-31 are also important areas for future research. addressing the global issue of insufficient sleep in adolescents requires a multi-pronged approach that considers the interplay of biological, environmental, and psychosocial factors and promotes a culture of prioritizing sleep for optimal health and well-being. acknowledgements: nori zapata, msn, rn, is the senior vice president of education and career development; vanessa vera, ms, is the senior manager of high school and community outreach; and anisa mirza is the intern program coordinator. funding: funded by dhr health high school and community outreach; dhr health; south texas independent school district. references 1. bradman a, castorina r, thilakaratne r, et al. dietary exposure to united states food and drug administration-approved synthetic food colors in children, pregnant women, and women of childbearing age living in the united states. international journal of environmental research and public health. 2022;19(15):9661. doi:https://doi.org/10.3390/ijerph19159661 2. perkins ej, to kt, lindsey st. mary, et al. developmental, behavioral and transcriptomic changes in zebrafish embryos after smoke dye exposure. toxics. 2022;10(5):210-210. doi:https://doi.org/10.3390/toxics10050210 3. sharkey j, meyer ru, st. john j. promotora‐academic partnership to reduce nutritional health disparities among mexican‐heritage families in texas border colonias. the faseb journal. 2016;30(s1). doi:https://doi.org/10.1096/fasebj.30.1_supplement.901.11 4. stein do, chakraborty j. racial, ethnic, and socioeconomic disparities in exposure to fast food in hillsborough county, florida. florida public health review. 2010;7(1):83-92. 5. monda a, ida m, villano i, et al. ultra-processed food intake and increased risk of obesity: a narrative review. foods. 2024;13(16):2627-2627. doi:https://doi.org/10.3390/foods13162627 6. prescott sl, d’adamo cr, holton kf, ortiz s, overby n, logan ac. beyond plants: the ultra-processing of global diets is harming the health of people, places, and planet. international journal of environmental research and public health. 2023;20(15):6461. doi:https://doi.org/10.3390/ijerph20156461 7. marks ab. taming america’s sugar rush: a traffic-light label approach. ssrn electronic journal. 2020;62(683). doi:https://doi.org/10.2139/ssrn.3731112 https://doi.org/10.3390/ijerph19159661 https://doi.org/10.3390/toxics10050210 https://doi.org/10.1096/fasebj.30.1_supplement.901.11 https://doi.org/10.3390/foods13162627 https://doi.org/10.3390/ijerph20156461 https://doi.org/10.2139/ssrn.3731112 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.4 dhr proceedings ǀ http://dhrproceedings.org 29 2024, vol. 4 no. s2 pg. 24-31 8. apergi k, malisova o, vlassopoulos a, fidanoglou p, kandyliari a, kapsokefalou m. investigating the sociodemographic and health characteristics of non-sugar sweeteners consumption in greek school-aged children: a cross-sectional study. children. 2024;11(7):813. doi:https://doi.org/10.3390/children11070813 9. hem-lee-forsyth s, sandoval b, bryant h. a tridimensional view of the hispanic health paradox: its relationship with faith, the enclave theory, and familism. advances in social sciences research journal. 2021;8(12):317-345. doi:https://doi.org/10.14738/assrj.812.11476 10. kronenfeld jp, graves kd, penedo fj, yanez b. overcoming disparities in cancer: a need for meaningful reform for hispanic and latino cancer survivors. the oncologist. 2021;26(6):443-452. doi:https://doi.org/10.1002/onco.13729 11. mota-bertran a, coenders g, plaja p, saez m, barceló ma. air pollution and children’s mental health in rural areas: compositional spatio-temporal model. scientific reports. 2024;14(1):1-13. doi:https://doi.org/10.1038/s41598-024-70024-2 12. larroya a, pantoja j, codoñer-franch p, cenit mc. towards tailored gut microbiome-based and dietary interventions for promoting the development and maintenance of a healthy brain. frontiers in pediatrics. 2021;9. doi:https://doi.org/10.3389/fped.2021.705859 13. berding k, vlckova k, marx w, et al. diet and the microbiota–gut–brain axis: sowing the seeds of good mental health. advances in nutrition. 2021;12(4). doi:https://doi.org/10.1093/advances/nmaa181 14. briant kj, sanchez j, galvan a, gonzalez v, wu-georges s, thompson b. abstract a35: eat healthy, be active community workshops for a rural hispanic population. cancer epidemiology biomarkers & prevention. 2017;26(2_supplement):a35-a35. doi:https://doi.org/10.1158/1538-7755.disp16-a35 15. andreea ioana enache (bontos, marius daniel bontos, danut ionel vaireanu. a novel information system for studying the interactions between, foods, food additives and packaging materials. revista de chimie. 2013;64(10):1139-1142. https://www.researchgate.net/publication/262609981_a_novel_information_system _for_studying_the_interactions_between_foods_food_additives_and_packaging_m aterials 16. wheaton ag. short sleep duration among infants, children, and adolescents aged 4 months–17 years — united states, 2016–2018. mmwr morbidity and mortality weekly report. 2021;70(38). doi:https://doi.org/10.15585/mmwr.mm7038a1 17. zimmermann lk. chronotype and the transition to college life. chronobiology international. 2011;28(10):904-910. doi:https://doi.org/10.3109/07420528.2011.618959 18. mark lawrence wong, nagata jm, barreto m. sleep and socioemotional outcomes among sexual and gender minority adolescents: a longitudinal study. archives of https://doi.org/10.3390/children11070813 https://doi.org/10.14738/assrj.812.11476 https://doi.org/10.1002/onco.13729 https://doi.org/10.1038/s41598-024-70024-2 https://doi.org/10.3389/fped.2021.705859 https://doi.org/10.1093/advances/nmaa181 https://doi.org/10.1158/1538-7755.disp16-a35 https://www.researchgate.net/publication/262609981_a_novel_information_system_for_studying_the_interactions_between_foods_food_additives_and_packaging_materials https://www.researchgate.net/publication/262609981_a_novel_information_system_for_studying_the_interactions_between_foods_food_additives_and_packaging_materials https://www.researchgate.net/publication/262609981_a_novel_information_system_for_studying_the_interactions_between_foods_food_additives_and_packaging_materials https://doi.org/10.15585/mmwr.mm7038a1 https://doi.org/10.3109/07420528.2011.618959 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.4 dhr proceedings ǀ http://dhrproceedings.org 30 2024, vol. 4 no. s2 pg. 24-31 sexual behavior. published online november 22, 2023. doi:https://doi.org/10.1007/s10508-023-02732-1 19. keuppens l, marten f, dieter baeyens, boyer b, danckaerts m, van. sleep intervention as symptom treatment for adhd (siesta)-blended cbt sleep intervention to improve sleep, adhd symptoms and related problems in adolescents with adhd: protocol for a randomised controlled trial. bmj open. 2023;13(4):e065355-e065355. doi:https://doi.org/10.1136/bmjopen-2022-065355 20. kim j, vander stoep a, mccauley e. 0394 differential role of sleep problems on depression and suicide in community adolescents. sleep. 2020;43(supplement_1):a151-a151. doi:https://doi.org/10.1093/sleep/zsaa056.391 21. shen c, mireku mo, martina di simplicio, et al. bidirectional associations between sleep problems and behavioural difficulties and health‐related quality of life in adolescents: evidence from the scamp longitudinal cohort study. jcpp advances. 2022;2(3). doi:https://doi.org/10.1002/jcv2.12098 22. shen c, smith rb, heller j, et al. depression and anxiety in adolescents during the covid-19 pandemic in relation to the use of digital technologies: longitudinal cohort study. journal of medical internet research. 2024;26(1):e45114. doi:https://doi.org/10.2196/45114 23. mcmakin dl, alfano ca. sleep and anxiety in late childhood and early adolescence. current opinion in psychiatry. 2015;28(6):483-489. doi:https://doi.org/10.1097/yco.0000000000000204 24. thapa s, yadav dk. role of sleep problem on suicidal behaviour and non-suicidal self-injury among adolescents in pokhara, nepal. islam mds, ed. plos one. 2024;19(9):e0305221. doi:https://doi.org/10.1371/journal.pone.0305221 25. chang ly, chang hy, lin ln, wu cc, yen ll. transitions in sleep problems from late adolescence to young adulthood: a longitudinal analysis of the effects of peer victimization. aggressive behavior. 2017;44(1):69-82. doi:https://doi.org/10.1002/ab.21725 26. wolfson ar, harkins e, johnson m, marco c. effects of the young adolescent sleep smart program on sleep hygiene practices, sleep health efficacy, and behavioral well-being. sleep health. 2015;1(3):197-204. doi:https://doi.org/10.1016/j.sleh.2015.07.002 27. gupta m, gupta n, fradkin y, petti t. sleep disturbances in children and adolescents with autism spectrum disorder: an overview for clinicians. adolescent psychiatry. 2023;13. doi:https://doi.org/10.2174/2210676613666230126115646 28. morales-muñoz i, durdurak bb, bilgin a, marwaha s, winsper c. understanding the relationship between sleep problems in early childhood and borderline personality disorder: a narrative review. nature and science of sleep. 2021;volume 13:21752202. doi:https://doi.org/10.2147/nss.s31167229 https://doi.org/10.1007/s10508-023-02732-1 https://doi.org/10.1136/bmjopen-2022-065355 https://doi.org/10.1093/sleep/zsaa056.391 https://doi.org/10.1002/jcv2.12098 https://doi.org/10.2196/45114 https://doi.org/10.1097/yco.0000000000000204 https://doi.org/10.1371/journal.pone.0305221 https://doi.org/10.1002/ab.21725 https://doi.org/10.1016/j.sleh.2015.07.002 https://doi.org/10.2174/2210676613666230126115646 https://doi.org/10.2147/nss.s31167229 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.4 dhr proceedings ǀ http://dhrproceedings.org 31 2024, vol. 4 no. s2 pg. 24-31 29. chattu v, manzar md, kumary s, burman d, spence d, pandi-perumal s. the global problem of insufficient sleep and its serious public health implications. healthcare. 2018;7(1):1. doi:https://doi.org/10.3390/healthcare7010001 https://doi.org/10.3390/healthcare7010001 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.6 dhr proceedings ǀ http://dhrproceedings.org 48 2024, vol. 4 no. s2 pg. 42-54 manuscript vaping and respiratory health: a literature review focused on hispanic adolescents in the rio grande valley marisol acosta1, edely sanchez1,2, desirae urbina1,3, diego sierra1,2, sofia p. prukop1,2, carlos garza1,2, john luna1,3, renata cantu-cepeda1,3 1 dhr health high school and community outreach 2 south texas isd medical professions 3 south texas isd health professions received: july 3, 2024 accepted for publication: january 24, 2025 introduction the rising prevalence of e-cigarette use among adolescents is a significant public health concern, particularly within specific demographic groups and geographic locations. this literature review focuses on the impact of vaping on respiratory health among hispanic adolescents residing in the rio grande valley (rgv), a region characterized by unique sociocultural factors and health disparities. the rgv, situated on the texas-mexico border, presents a complex context where cultural influences, socioeconomic factors, and access to healthcare intersect to shape adolescent health behaviors. this review synthesizes existing research on vaping's effects on respiratory health in adolescents, with a specific focus on the hispanic population in the rgv, highlighting the need for culturally sensitive interventions and future research. prevalence of e-cigarette use among hispanic adolescents in the rgv while precise data on e-cigarette prevalence specifically within the rgv's hispanic adolescent population is limited, national and state-level studies provide a crucial foundation for understanding the scope of the problem. national surveys consistently reveal high rates of ecigarette use among adolescents, and these trends likely mirror, or even exceed, those observed in specific high-risk communities like the rgv.1,3 the rgv's unique border location and cultural dynamics may contribute to increased accessibility and normalization of vaping among youth.4 further research is needed to obtain accurate, rgv-specific data on e-cigarette prevalence among hispanic adolescents, considering factors such as access to tobacco products, cultural norms, and marketing strategies targeting this demographic. the lack of localized data represents a significant gap in the current literature.5 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.6 dhr proceedings ǀ http://dhrproceedings.org 49 2024, vol. 4 no. s2 pg. 42-54 respiratory effects of vaping in adolescents: general findings numerous studies demonstrate a clear association between e-cigarette use and various respiratory problems in adolescents.1,6-13 these effects range from increased respiratory symptoms like wheezing and coughing to more severe conditions like evali (e-cigarette or vaping product use-associated lung injury).11,14-20 studies have shown that e-cigarette aerosols contain various harmful chemicals, including flavorings, that can directly damage the respiratory system.7-8, 21-24 the long-term effects remain largely unknown, necessitating further longitudinal research to fully understand the cumulative impact of vaping on adolescent respiratory health.8,13,22 asthma and vaping the impact of vaping on adolescents with asthma is a particularly pressing concern.6-7 existing evidence suggests that e-cigarette use can exacerbate asthma symptoms, potentially leading to increased frequency and severity of asthma attacks.6,7 the inflammatory and irritant effects of ecigarette aerosols can worsen airway inflammation and hyperresponsiveness in asthmatic individuals.25 however, more research is needed to establish a definitive causal link and quantify the extent of this risk within the hispanic adolescent population in the rgv.6 the existing research often lacks the specificity needed to address the unique health challenges faced by this population. secondhand exposure the effects of secondhand exposure to e-cigarette aerosol are also concerning.7,16 studies have shown that exposure to secondhand vape can lead to respiratory symptoms in non-users.16 this is especially relevant in the rgv, where multigenerational households are common, potentially exposing younger children to secondhand vaping aerosols.26 this area needs further investigation, particularly within the specific context of the rgv's social and family structures. data on secondhand exposure and its impact on respiratory health within hispanic families in the rgv are scarce.26 socio-cultural factors influencing vaping in the rgv the rgv's unique cultural context plays a crucial role in shaping adolescent health behaviors, including vaping. the region's high hispanic population, strong family ties, and bicultural influences, all contribute to the complex social environment in which adolescents make decisions about vaping.26-30 acculturation stress, family cohesion, and social support networks within the family and community may influence vaping initiation and persistence.27-28 further research is needed to explore the interplay of these cultural factors and their influence on vaping among hispanic adolescents in the rgv. qualitative studies exploring the perspectives of hispanic adolescents and their families could provide valuable insights into this complex relationship.4 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.6 dhr proceedings ǀ http://dhrproceedings.org 50 2024, vol. 4 no. s2 pg. 42-54 marketing and accessibility the marketing and accessibility of e-cigarettes in the rgv also warrant investigation. the proximity to the mexican border may affect the availability and affordability of vaping products.4 marketing strategies targeting specific cultural groups or exploiting existing social norms could influence vaping uptake among hispanic adolescents.4 research on marketing strategies and their effectiveness within the rgv's hispanic community is crucial for developing targeted prevention efforts. socioeconomic factors socioeconomic factors may also play a significant role in vaping prevalence and its health consequences among hispanic adolescents in the rgv. poverty, limited access to healthcare, and lower health literacy could exacerbate the negative impacts of vaping on respiratory health.4 studies need to investigate how socioeconomic disparities influence vaping patterns and the severity of respiratory complications within this specific population. research gaps and future directions several significant research gaps remain in understanding the impact of vaping on respiratory health among hispanic adolescents in the rgv. there is a critical need for: rgv-specific data: more research is needed to gather precise data on e-cigarette prevalence, patterns of use, and respiratory health outcomes within the rgv's hispanic adolescent population. longitudinal studies: longitudinal studies are necessary to track the long-term respiratory effects of vaping in this population, considering the relatively recent introduction of e-cigarettes. culturally sensitive research: qualitative studies employing culturally sensitive methodologies are needed to understand the sociocultural factors influencing vaping initiation, cessation, and health outcomes within the rgv's hispanic community. intervention studies: research on the effectiveness of culturally tailored interventions to prevent vaping initiation and promote cessation among hispanic adolescents in the rgv is crucial. secondhand exposure research: further investigation is needed to assess the impact of secondhand e-cigarette aerosol exposure on the respiratory health of hispanic children and families in the rgv. combined substance use: research needs to address the complex interplay between vaping and other substance use (e.g., alcohol, marijuana) among hispanic adolescents in the rgv, given the potential for synergistic effects on respiratory health. special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.6 dhr proceedings ǀ http://dhrproceedings.org 51 2024, vol. 4 no. s2 pg. 42-54 conclusion the growing prevalence of e-cigarette use among adolescents, coupled with the rgv's unique sociocultural context and health disparities, necessitates urgent research to understand and address this critical public health issue. this review highlights the existing evidence on the detrimental effects of vaping on respiratory health, emphasizing the need for rgv-specific studies that incorporate cultural nuances, socioeconomic factors, and the complex interplay of various influences on adolescent health behaviors. future research should focus on generating localized data, employing longitudinal and qualitative methods, and developing and evaluating culturally appropriate interventions to mitigate the significant respiratory health risks associated with vaping among hispanic adolescents in the rio grande valley. addressing this challenge requires a multi-faceted approach involving public health initiatives, educational programs, and policy changes tailored to the specific needs of this vulnerable population. acknowledgements: nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. funding: funded by dhr health high school and community outreach; dhr health; south texas independent school district. references 1. tahniyath u, begum ss, unnisa m. vaping trends among adoloscents: understanding the rise of e cigarettes in youth culture. journal of advances in medical and pharmaceutical sciences. 2024;26(8):48-63. doi:https://doi.org/10.9734/jamps/2024/v26i8707 2. buettner-schmidt k, fraase ks, barnacle m, et al. a review of vaping’s health effects, treatment, and policy implications: nursing’s call to action. the nurse practitioner. 2024;49(9):36-47. doi:https://doi.org/10.1097/01.npr.0000000000000221 3. natalia sejnowska, katarzyna dobko, gabriela frącz, et al. evaluation of the frequency of e-cigarette usage among high school students and factors that influence vaping. adolescents’ knowledge of chemical composition of e-cigarettes and side effects. journal of education, health and sport. 2023;16(1). doi:https://doi.org/10.12775/jehs.2023.16.01.010 4. mccausland k, booth s, leaversuch f, et al. socio-ecological factors that influence youth vaping: perspectives from western australian school professionals, parents and young people. international journal of qualitative studies on health and well-being. 2024;19(1):2322753. doi:https://doi.org/10.1080/17482631.2024.2322753 https://doi.org/10.9734/jamps/2024/v26i8707 https://doi.org/10.1097/01.npr.0000000000000221 https://doi.org/10.12775/jehs.2023.16.01.010 https://doi.org/10.1080/17482631.2024.2322753 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.6 dhr proceedings ǀ http://dhrproceedings.org 52 2024, vol. 4 no. s2 pg. 42-54 5. cohen n, jeter j, schissler k, lozano j, maniaci v, peña b. poor perception and knowledge of electronic cigarettes among adolescents and their parents. pediatric emergency care. 2021;publish ahead of print. doi:https://doi.org/10.1097/pec.0000000000002339 6. kurdyś-bykowska p, kośmider l, dawid konwant, stencel-gabriel k. e-cigarettes use and respiratory symptoms in asthmatic and non-asthmatic adolescents – a systematic review. paediatrics & family medicine/pediatria & medycyna rodzinna. 2024;20(1):29-36. doi:https://doi.org/10.15557/pimr.2024.0004 7. di cicco m, sepich m, ragazzo v, peroni dg, comberiati p. potential effects of ecigarettes and vaping on pediatric asthma. minerva pediatrica. 2020;72(5). doi:https://doi.org/10.23736/s0026-4946.20.05973-3 8. cambron c. racial/ethnic differences in vaping product use among youth: a statelevel analysis. racial/ethnic differences in vaping product use among youth: a state-level analysis. 2023;20(9):5729-5729. doi:https://doi.org/10.3390/ijerph20095729 9. shubochkina ei, guryanova mp, kurgansky am, khramtsov pi, gorelova jyu, anufrieva ev. the impact of electronic cigarettes smoking on the health of adolescents and young adults. здоровье населения и среда обитания знисо / public health and life environment. published online june 2024:54-63. doi:https://doi.org/10.35627/2219-5238/2024-32-6-54-63 10. grigoryev ki, o.f. vykhristyuk, grigoryev ai. vaping, as a reincarnation of smoking, requires solving the problem of harm to health in essence. meditsinskaya sestra. 2024;26(4):3-10. doi:https://doi.org/10.29296/25879979-2024-05-01 11. ishbuldina av, vakhitov kм, gaichik еа. the impact of vaping on the health of children and adolescents. rossiyskiy vestnik perinatologii i pediatrii (russian bulletin of perinatology and pediatrics). 2024;69(5):22-28. doi:https://doi.org/10.21508/1027-4065-2024-69-5-22-28 12. krishna a, mathieu w, mull e, tobias jd. perioperative implications of vaping. journal of medical cases. 2020;11(5):129-134. doi:https://doi.org/10.14740/jmc3451 13. verma s. vaping: from public health crisis to impacting sars-cov-2 pandemic. american journal of epidemiology & public health. 2021;5(1):036-041. 14. tackett ap, keller-hamilton b, smith ce, et al. evaluation of respiratory symptoms among youth e-cigarette users. jama network open. 2020;3(10):e2020671. doi:https://doi.org/10.1001/jamanetworkopen.2020.20671 15. chaffee bw, barrington-trimis j, liu f, et al. e-cigarette use and adverse respiratory symptoms among adolescents and young adults in the united states. preventive medicine. 2021;153:106766. doi:https://doi.org/10.1016/j.ypmed.2021.10676 https://doi.org/10.1097/pec.0000000000002339 https://doi.org/10.15557/pimr.2024.0004 https://doi.org/10.23736/s0026-4946.20.05973-3 https://doi.org/10.3390/ijerph20095729 https://doi.org/10.35627/2219-5238/2024-32-6-54-63 https://doi.org/10.29296/25879979-2024-05-01 https://doi.org/10.21508/1027-4065-2024-69-5-22-28 https://doi.org/10.14740/jmc3451 https://doi.org/10.1001/jamanetworkopen.2020.20671 https://doi.org/10.1016/j.ypmed.2021.10676 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.6 dhr proceedings ǀ http://dhrproceedings.org 53 2024, vol. 4 no. s2 pg. 42-54 16. islam t, braymiller j, eckel sp, et al. secondhand nicotine vaping at home and respiratory symptoms in young adults. thorax. 2022;77(7). doi:https://doi.org/10.1136/thoraxjnl-2021-217041 17. li d, sundar ik, mcintosh s, et al. association of smoking and electronic cigarette use with wheezing and related respiratory symptoms in adults: cross-sectional results from the population assessment of tobacco and health (path) study, wave 2. tobacco control. published online february 13, 2019:tobaccocontrol-2018-054694. doi:https://doi.org/10.1136/tobaccocontrol-2018-054694 18. harrell mb, clendennen sl, sumbe a, case kr, mantey ds, swan s. cannabis vaping among youth and young adults: a scoping review. current addiction reports. published online may 7, 2022. doi:https://doi.org/10.1007/s40429-02200413-y 19. hartung m. vaping-associated lung injury. radiopaediaorg. published online october 16, 2019. doi:https://doi.org/10.53347/rid-71664 20. tzortzi a, kapetanstrataki m, evangelopoulou v, behrakis p. a systematic literature review of e-cigarette-related illness and injury: not just for the respirologist. international journal of environmental research and public health. 2020;17(7). doi:https://doi.org/10.3390/ijerph17072248 21. martin a, tempra c, yu y, et al. exposure to aldehyde cherry e-liquid flavoring and its vaping byproduct disrupt pulmonary surfactant biophysical function. environmental science & technology. published online january 8, 2024. doi:https://doi.org/10.1021/acs.est.3c07874 22. ali sah. editorial: vaping and cardiovascular health: an opportunity or a risk? the journal of cardiovascular diseases. 2022;18(2). doi:https://doi.org/10.55958/jcvd.v18i2.107 23. barrington-trimis jl, samet jm, mcconnell r. flavorings in electronic cigarettes. jama. 2014;312(23):2493. doi:https://doi.org/10.1001/jama.2014.14830 24. mcconnell r, barrington-trimis jl, wang k, et al. electronic cigarette use and respiratory symptoms in adolescents. american journal of respiratory and critical care medicine. 2017;195(8):1043-1049. doi:https://doi.org/10.1164/rccm.2016040804oc 25. ferkol t. the threat of vaping in youths. pediatric pulmonology. published online october 28, 2024. doi:https://doi.org/10.1002/ppul.27361 26. lee h. determinants of living in a three-generation household among adolescents of ethnic groups in the u.s.: family structure, social–economic status, and cultural factors. sustainability. 2023;15(13):10460. doi:https://doi.org/10.3390/su151310460 27. forster m, dyal sr, baezconde-garbanati l, chou cp, soto dw, unger jb. bullying victimization as a mediator of associations between cultural/familial variables, https://doi.org/10.1136/thoraxjnl-2021-217041 https://doi.org/10.1136/tobaccocontrol-2018-054694 https://doi.org/10.1007/s40429-022-00413-y https://doi.org/10.1007/s40429-022-00413-y https://doi.org/10.53347/rid-71664 https://doi.org/10.3390/ijerph17072248 https://doi.org/10.1021/acs.est.3c07874 https://doi.org/10.55958/jcvd.v18i2.107 https://doi.org/10.1001/jama.2014.14830 https://doi.org/10.1164/rccm.201604-0804oc https://doi.org/10.1164/rccm.201604-0804oc https://doi.org/10.1002/ppul.27361 https://doi.org/10.3390/su151310460 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.6 dhr proceedings ǀ http://dhrproceedings.org 54 2024, vol. 4 no. s2 pg. 42-54 substance use, and depressive symptoms among hispanic youth. ethnicity & health. 2013;18(4):415-432. doi:https://doi.org/10.1080/13557858.2012.754407 28. martin cl, mcmorris bj, eisenberg me, et al. weight status among minnesota hispanic or latino/a youth: an exploration of protective factors. american journal of health promotion. 2022;37(2):177-188. doi:https://doi.org/10.1177/08901171221120912 29. dandy j, caroline ng tseung-wong, george am, zamboanga bl, palacios v. cultural factors in alcohol and other drug use among immigrant youth in western australia: a qualitative investigation. cultural diversity & ethnic minority psychology. published online may 16, 2024. doi:https://doi.org/10.1037/cdp0000659 30. dai h, ramos ak, faseru b, hill jl, sussman sy. racial disparities of e-cigarette use among us youths: 2014‒2019. american journal of public health. 2021;111(11):2050-2058. doi:https://doi.org/10.2105/ajph.2021.306448 https://doi.org/10.1080/13557858.2012.754407 https://doi.org/10.1177/08901171221120912 https://doi.org/10.1037/cdp0000659 https://doi.org/10.2105/ajph.2021.306448 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 1 2024, vol. 4 no. s1 pg. 1-14 manuscript obesity and food affordability: the influence of addictive processed foods in hispanic young adults marisol acosta1, victoria delgado1,2, mayte chapa 1, natalee alvarez1,3, dariana garza1,4, sarai aboytes1,6, allison, hernandez1,4 1dhr health high school and community outreach 2 south texas isd world scholars 3 san isidro high school 4 la joya high school 5 psja early college high school 6 rio hondo high school received: july 3rd, 2024 accepted for publication: january 6, 2025 introduction obesity presents a significant public health challenge globally, disproportionately affecting hispanic young adults [1]. while obesity rates have plateaued in some u.s. demographics, they continue to rise among hispanic young adults group, raising concerns due to the associated longterm health consequences like cardiovascular disease, type 2 diabetes, and certain cancers [2]. understanding the contributing factors to this disparity is crucial for developing effective interventions. several factors, including genetic predisposition, maternal obesity, and prenatal exposures, have been suggested [2]. however, the simultaneous rise in obesity across various ethnicities and age groups suggests broader influences like changes in food production, marketing, and the availability of affordable, energy-dense foods [2]. the most significant increase in obesity prevalence between 1991 and 1998 was observed among individuals aged 18–29 years [3], emphasizing the importance of focusing on this age group, especially within the hispanic population, to mitigate long-term health risks associated with early-onset obesity. food affordability is a critical factor shaping dietary choices and influencing obesity risk, particularly among socioeconomically disadvantaged populations. access to affordable, nutritious food is often limited in low-income communities, leading to a reliance on cheaper, energy-dense, and nutrient-poor options [4]. this disparity in food access is linked to "food deserts," areas with limited access to healthy and affordable food [5]. addictive processed foods, characterized by high fat, sugar, and salt content, are also a significant driver of obesity, particularly among young adults [6]. these foods, often termed "highly processed" or "ultra-processed," are designed for palatability and reward, triggering brain responses similar to drugs of abuse [7], [6]. the special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 2 2024, vol. 4 no. s1 pg. 1-14 incentive sensitization theory suggests that the craving or "wanting" aspect of these foods, rather than enjoyment, drives compulsive consumption and contributes to problematic eating behaviors and weight gain [6]. epidemiology of obesity in hispanic young adults obesity among hispanic young adults includes prevalence statistics, contributing risk factors, and comparisons with other ethnic groups, highlighting the need for targeted interventions. understanding these specific challenges is crucial for targeted interventions and public health initiatives. prevalence of obesity in hispanic young adults studies highlight an alarming prevalence of obesity among hispanic young adults [8]. schulte and gearhardt found higher obesity prevalence in hispanic individuals compared to nonhispanic white individuals, underscoring the need for focused research and interventions within the hispanic community [8]. while nelson et al. discussed weight gain and related behaviors in emerging adulthood and college-aged youth [3], and white et al. explored the impact of retail access on dietary intake [5], neither study specifically focused on hispanic populations. miller et al. investigated the link between acculturation, familial support, and dietary patterns in a latino population, revealing that increased acculturation was associated with decreased dietary quality and increased fast food consumption [9]. eskandari et al. conducted a mixed-methods review on the influences of food environments and food insecurity on obesity, finding a significant association between food insecurity and obesity [10]. this adds another layer of complexity, particularly for vulnerable populations like hispanic young adults who may experience higher rates of food insecurity. risk factors contributing to obesity in hispanic young adults multiple risk factors contribute to the high obesity prevalence among hispanic young adults, encompassing genetic, environmental, socioeconomic, and cultural influences. miller et al. identified a strong association between acculturation and unhealthy dietary patterns, with usborn, english-speaking hispanics consuming more fast food and processed food [9]. this suggests that cultural shifts associated with acculturation play a significant role. socioeconomic factors also contribute. kim and tsoh found that food insecurity was significantly associated with current smoking and suggested that socioeconomically disadvantaged young adults experiencing food insecurity may be at high risk for unhealthy behaviors, including overeating [11]. polk et al.'s research on wanting and liking in problematic eating behavior further emphasizes the role of highly processed foods, which are craved more and positively associated with food addiction symptoms [6]. wattick et al. examined the impact of early life influences on special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 3 2024, vol. 4 no. s1 pg. 1-14 food addiction in college-attending young adults, highlighting the role of adverse childhood experiences (aces) and mental health [12]. while not specifically focused on hispanic young adults, the findings suggest these are important factors to consider. comparative analysis between hispanic and other ethnic groups comparative analyses reveal disparities in obesity prevalence and associated risk factors. schulte and gearhardt found that the prevalence of food addiction, measured by the yale food addiction scale, was higher among hispanic individuals compared to non-hispanic white individuals [8]. this suggests food addiction may be a more significant contributor to obesity within the hispanic community. maqsood et al. examined the cumulative impact of social determinants of health on obesity, finding a stronger association between unfavorable social determinants and obesity in young adults compared to older populations [1]. rodgers et al. discussed prevalence trends in the u.s. obesity epidemic, noting a simultaneous increase in weight across different ethnic groups [2]. gearhardt et al. examined the relationship between bmi across adolescence and substance use problems in early adulthood, finding that obese adolescents had fewer drinking and illicit drug problems [13]. food affordability and accessibility the relationship between food affordability, accessibility, and obesity among hispanic young adults, exploring how socioeconomic status shapes food choices, the impact of food deserts, and the role of government policies. socioeconomic status and food choices socioeconomic status (ses) significantly impacts dietary habits, determining the types and quality of food consumed. lower ses is often associated with limited access to nutritious foods due to financial constraints [5]. polk et al. found that highly processed foods, often cheaper and more readily available, are craved more overall [6]. this preference for highly processed foods, high in fat and refined carbohydrates, contributes to increased obesity risk. research suggests that restraint in food choices is negatively associated with both craving and liking of highly processed foods [6]. individuals with lower ses, having less flexibility in their food choices, may be more vulnerable to consuming highly processed foods, potentially leading to adverse health outcomes. access to transportation and information also influences dietary choices. limited transportation restricts access to supermarkets with diverse fresh and healthy options, leading to reliance on convenience stores stocking primarily processed foods [5]. limited access to nutrition education hinders informed food choices [3], perpetuating unhealthy eating habits. limited disposable income further restricts access to healthier options [5]. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 4 2024, vol. 4 no. s1 pg. 1-14 food deserts and dietary habits food deserts, areas with limited access to affordable and nutritious food, exacerbate dietary challenges for lower ses individuals. these areas often lack supermarkets, leaving residents with limited options beyond convenience stores and fast-food restaurants offering primarily energy-dense, nutrient-poor foods [5]. white et al. emphasize considering transportation and proximity when evaluating food access [5]. physical distance and limited transportation can significantly restrict access to healthier choices. the scarcity of fresh produce and whole grains in food deserts further contributes to unhealthy dietary patterns, increasing obesity and related health risks [4]. research on food deserts shows mixed findings regarding the availability and cost of healthy options [5]. some studies suggest healthy foods are less available in poorer areas, while others find supermarkets in these areas offer comparable or even better availability of fresh produce. however, affordability remains a significant barrier for low-income individuals, even when healthy options are available [5]. the consumption of fast food and takeaway meals, readily available in many food deserts, further contributes to increased energy intake and a higher risk of obesity [14]. government policies, food pricing, and availability government policies significantly influence food environments, impacting affordability and accessibility. policies related to agricultural subsidies, food assistance programs, and nutrition labeling can affect food availability and cost [15], [16]. subsidies favoring certain crops, like corn and soybeans, can lead to oversupply and lower prices, making them prevalent in processed foods [15]. this can create price imbalances, making healthier options like fruits and vegetables relatively more expensive. food assistance programs, while aiming to alleviate food insecurity, can also influence dietary habits. some programs may restrict the types of food purchased, potentially limiting access to fresh produce [10]. reliance on food banks, often offering primarily shelf-stable and processed foods, can contribute to unhealthy dietary patterns [10]. nutrition labeling policies can empower consumers to make informed choices, but their effectiveness depends on consumer understanding [16]. policies restricting unhealthy food marketing to children, particularly highly processed foods and sugary drinks, can create healthier food environments [3]. taxation and subsidization schemes can influence food prices, making healthier options more affordable, such as taxing sugary beverages and subsidizing fruits and vegetables [4]. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 5 2024, vol. 4 no. s1 pg. 1-14 addictive processed foods the role of addictive processed foods in obesity, particularly among hispanic young adults, examining their characteristics, research findings on food addiction, and the underlying psychological and physiological mechanisms. characteristics of processed foods contributing to addictive eating behaviors highly processed foods, often high in added fats and/or refined carbohydrates, are implicated in problematic eating behaviors [6], [7]. engineered for hyper-palatability, they maximize desirable taste qualities like sweetness and fattiness, potentially leading to overconsumption and a cycle of craving and reward-seeking [7]. the incentive sensitization theory suggests that "wanting" or craving, rather than "liking," drives compulsive consumption [6]. this theory may apply to highly processed foods, as they can trigger intense cravings even without true hunger. the high energy density and rapid absorption of these foods can lead to rapid blood sugar spikes and subsequent crashes, potentially perpetuating craving and consumption [17]. trans fats, common in processed foods, are linked to food addiction in african american adolescents with obesity [18]. the combination of loss of control and consumption of large quantities of food, particularly those high in trans fats, appears key in food addiction. research findings on food addiction and its impact on dietary intake research on food addiction, primarily assessed using the yale food addiction scale (yfas), has shown associations with obesity, binge eating, and highly processed food consumption [18]. one study found that approximately 10% of african american adolescents with obesity met the criteria for food addiction using the yfas-c (children's version) [18]. yfas-c scores were strongly associated with objective binge episodes and, to a lesser extent, with percent overweight and subjective binge episodes [18]. higher yfas-c scores correlated with increased consumption of calories, fat, saturated fat, trans fat, carbohydrates, sugar, and added sugar, with the strongest association being with trans fat [18]. pursey et al.'s systematic review examined the relationship between addictive eating and dietary intake, finding that foods high in both fat and refined carbohydrates were commonly associated with addictive eating, and individuals with addictive eating consumed higher amounts of energy, carbohydrates, and fats [19]. however, the review noted heterogeneity in study methodologies and outcomes, making it difficult to draw definitive conclusions about specific foods, nutrients, or dietary patterns that facilitate the addictive process. a nationally representative u.s. study found a food addiction prevalence of 15%, with higher rates among younger, hispanic individuals, and those with higher incomes [8]. food addiction was associated with both underweight and obese individuals compared to those of normal or overweight. another systematic review, including twenty-five studies and 196,211 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 6 2024, vol. 4 no. s1 pg. 1-14 participants, found a weighted mean prevalence of food addiction of 19.9%, higher in adults over 35, females, and clinical samples [20]. psychological and physiological mechanisms of food addiction the mechanisms driving food addiction are complex and interconnected. the brain's reward system, involving dopamine pathways, plays a crucial role [7]. ultra-processed foods (upfs), with their high palatability and energy density, can trigger strong rewarding stimuli, influencing feeding facilitation circuits [7]. this can lead to a cycle of craving, consumption, and reward, similar to substance use disorders [21]. gordon et al.'s systematic review found support for various addiction characteristics related to food, including brain reward dysfunction, impaired control, and tolerance/withdrawal [21]. evidence suggests that processed foods high in sweeteners and fats have the greatest addictive potential. wiss et al. highlighted stress, trauma, and adversity, especially during early life, as contributing factors to both drug and food addictions [22]. early adversity can cause lasting changes in glucocorticoid and dopamine systems, increasing addiction vulnerability. a study examining the relationship between childhood or adolescent abuse victimization and food addiction in adult women found that severe childhood abuse was associated with a roughly 90% increased risk of food addiction [23]. cummings et al. found that intake of sweet, high-fat foods, fast foods, and sugary drinks was associated with immediate increases in positive emotions and decreases in negative emotions, but these effects were short-lived [24]. this suggests that the ability of highly processed foods to briefly alter emotions may be key to their reinforcing nature. cultural factors influencing eating behaviors this section explores the cultural factors that influence eating behaviors, particularly within the hispanic community. cultural attitudes towards food in hispanic communities food is central to hispanic culture, encompassing social gatherings, celebrations, and expressions of love and connection [9]. shared meals reinforce family bonds and transmit cultural values. traditional hispanic cuisine often features fresh produce, legumes, and whole grains [15]. however, acculturation to american culture has shifted dietary patterns, with increased consumption of fast food, processed foods, and sugary drinks [9]. this shift is often attributed to accessibility and affordability, particularly in low-income communities [5]. miller et al. found that us-born, english-speaking hispanics consumed more fast and processed foods than their immigrant, spanish-speaking counterparts [9]. this cultural shift is complicated by the potential for these foods to trigger addictive-like behaviors. highly processed foods, often high in fat and refined carbohydrates, activate reward pathways in the brain [6]. this can lead to special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 7 2024, vol. 4 no. s1 pg. 1-14 increased cravings and difficulty controlling consumption. polk et al. found that highly processed foods were craved more overall, with craving positively associated with yale food addiction scale (yfas) scores [6]. this suggests the incentive sensitization framework, where "wanting" drives compulsive drug use, may also be relevant to problematic food consumption. family and social influences on food choices family and social networks are crucial in shaping eating behaviors within hispanic communities [25], [26]. traditional family structures emphasize shared meals and the importance of food in social gatherings. this can create a positive environment for healthy eating when traditional diets are followed, but can contribute to unhealthy patterns when processed foods become integrated. eneli et al. highlight family dynamics in the trust model of feeding, emphasizing the division of responsibility between caregivers and children in establishing healthy eating habits [26]. caregivers provide nutritious options, while children self-regulate intake, trusting internal cues of hunger and satiety. however, cultural factors and parental anxieties about weight or nutrition can interfere with this trust, leading to restrictive or pressuring feeding practices. social networks also influence food choices, particularly among young adults [25]. peer influences, social norms, and the availability of healthy food options within one's social environment all contribute to eating behaviors. li et al. note that social influence can promote or hinder healthy eating through various pathways, including instrumental support, informational support, and social integration [25]. the role of traditional dietary practices and their evolution traditional hispanic diets, rich in fruits, vegetables, legumes, and whole grains, offer protection against obesity [15]. however, these practices are evolving due to acculturation and changing food environments. increased availability and affordability of highly processed foods, combined with targeted marketing, contribute to a shift away from traditional diets [27]. this shift is pronounced among young adults, susceptible to peer influences and media messages promoting processed foods [3]. nelson et al. highlight the transition to young adulthood as critical for forming lasting dietary habits [3]. this period involves increasing autonomy but also a lack of adult responsibilities and financial stability, making young adults vulnerable to unhealthy choices. the transition to college can exacerbate these challenges, presenting new food choices and social norms, with increased access to fast food and less emphasis on traditional family meals [3]. kavle et al.'s research in egypt highlights the cultural perception of "junk foods" as essential, particularly for toddlers [27]. this resonates with miller et al.'s findings regarding increased processed food consumption among acculturated hispanics [9], suggesting a broader trend of incorporating processed foods into cultural norms. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 8 2024, vol. 4 no. s1 pg. 1-14 interventions and strategies this section explores interventions and strategies to mitigate the impact of food affordability and addictive processed foods on obesity in hispanic young adults. successful interventions targeting obesity in hispanic populations several interventions show promise. family-based interventions, incorporating behavioral therapy and lifestyle modifications, have demonstrated efficacy in reducing weight and improving health outcomes [26]. culturally tailored interventions considering specific cultural values, beliefs, and practices within hispanic communities have also shown success [27]. community-based interventions implemented through schools, churches, or community centers can reach wider audiences and address broader environmental factors [25]. pan et al. examined the association between fast food intake and coronary heart disease (chd) risk among singaporean chinese adults, revealing a significant association between frequent fast food consumption and increased chd risk [15]. this highlights the negative health impacts of consuming highly processed foods. addressing emotional and psychological factors associated with food addiction is crucial. programs incorporating cognitive behavioral therapy (cbt) or other evidence-based therapies can help manage cravings, develop coping mechanisms, and improve emotional regulation [24]. interventions focusing on social support networks and access to mental health services can further enhance effectiveness [28]. adolescence and young adulthood are critical periods for intervention [3]. school-based programs promoting healthy eating, physical activity, and media literacy can be impactful [25]. interventions targeting college-aged hispanic young adults are also essential [3]. policy recommendations to improve food affordability and access to healthy foods policy changes are vital for creating environments supporting healthy eating. improving food affordability and access to healthy options is particularly relevant for hispanic young adults, who often experience high rates of food insecurity [11]. key recommendations include increasing supplemental nutrition assistance program (snap) benefits and expanding eligibility [10]; promoting affordable healthy foods in underserved communities through farmers' markets, community gardens, and healthy corner store programs [5]; and zoning regulations limiting fastfood restaurant density and promoting grocery stores in low-income neighborhoods [16]. fiscal policies, such as taxes on sugar-sweetened beverages and subsidies for fruits and vegetables, can influence food choices [15], [4], [29]. taxes on unhealthy foods can generate revenue for programs promoting healthy eating and physical activity. policies regulating food marketing, especially targeting children and adolescents, can reduce exposure to unhealthy food advertising [3]. addressing food insecurity is crucial. food banks provide immediate relief, but long-term solutions require addressing the root causes of poverty and inequality. policies supporting special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 9 2024, vol. 4 no. s1 pg. 1-14 economic stability, like job training programs, affordable housing, and living wages, can improve food security and health outcomes [11]. community programs focused on reducing food addiction and promoting healthier eating community programs translate policy recommendations into actions. programs focusing on reducing food addiction and promoting healthier eating can be particularly effective in hispanic communities [9]. cooking classes and nutrition education workshops empower individuals to make healthier choices [25]. community gardens and urban farms increase access to fresh produce and provide opportunities for physical activity [5]. support groups and peer counseling offer social support for those struggling with food addiction [13]. interventions should be culturally tailored to address the specific needs of hispanic young adults [30]. community health workers (chws) can deliver culturally competent interventions and connect individuals with resources [31]. partnering with faith-based organizations can leverage existing social networks and provide access to wider audiences [32]. community programs should address broader environmental factors contributing to food addiction and obesity. collaborating with local businesses to improve healthy food availability and reduce unhealthy product marketing can create healthier food environments [5]. advocating for policy changes supporting healthy eating and physical activity can create systemic change [33]. ongoing program evaluation and refinement are essential. collecting data on participation, outcomes, and community impact can inform program improvements [34]. sharing best practices expands the reach of successful programs. the incentive sensitization theory may be relevant for problematic food consumption, particularly for individuals experiencing food addiction symptoms [6]. current treatment approaches for addictive eating could incorporate individualized dietary advice targeting foods high in fat and refined carbohydrates [19]. the yale food addiction scale (yfas) has been associated with obesity, eating-related problems, and problematic consumption of highly processed foods [18]. conclusion this review explored the complex interplay of food affordability, addictive processed foods, and obesity among hispanic young adults, examining sociocultural factors influencing dietary habits, the neurobiological mechanisms of food addiction, and the public health implications. summary of key findings the literature consistently shows a disproportionate obesity burden among hispanic populations [15], [9], [35]. acculturation shifts dietary patterns toward increased consumption of processed foods and sugary beverages [9], accompanied by reduced intake of fruits, vegetables, and whole grains [15]. highly processed foods, often more affordable, may trigger addictive-like responses, special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 10 2024, vol. 4 no. s1 pg. 1-14 contributing to problematic eating behaviors [6]. the incentive sensitization framework, where "wanting" drives compulsive consumption [6], may be relevant. craving and liking are distinct in relation to processed foods [6]. craving is associated with addictive-like eating and cognitive restraint, while liking is linked to bmi. food addiction prevalence varies across populations [18], [8], [20]. in african american adolescents with obesity, food addiction is linked to binge eating and processed food consumption [18]. foods high in fat and refined carbohydrates are commonly associated with addictive eating [19]. processed food intake is linked to short-term alterations in emotions [24]. early life experiences and environmental factors shape eating behaviors and obesity risk [3], [12], [26]. the transition to young adulthood, especially college, is a critical period for developing unhealthy habits [3]. food insecurity is linked to increased reliance on energy-dense, nutrient-poor foods [10]. the covid-19 pandemic exacerbated childhood obesity challenges [4]. implications for future research future research should include longitudinal studies on the long-term effects of processed food consumption on emotional regulation and eating behaviors [24]; research on the relationship between food addiction and other mental health conditions [12]; culturally tailored interventions addressing sociocultural factors influencing dietary habits among hispanic young adults [27]; studies on the effectiveness of the trust model of feeding in diverse populations [26]; and research on the impact of social networks and social media on food choices [25]. further investigation is needed to understand the interplay of genetic, environmental, and psychosocial factors in shaping food preferences. studies examining marketing's influence on food choices, particularly among vulnerable populations [3], are needed. research exploring the long-term effects of early life experiences, like aces and childhood eating environments, on food addiction and obesity is warranted [12]. evaluating the effectiveness of dietary and lifestyle interventions, including technology-based approaches [25], is essential. call to action for policy changes and community initiatives this review highlights the need for multi-level interventions to address obesity among hispanic young adults. policy changes improving food affordability and accessibility, like subsidies for healthy foods and taxes on sugary beverages, are needed [15]. community initiatives promoting healthy eating habits, such as nutrition education programs and cooking classes, could empower individuals [16]. collaborations between healthcare providers, schools, and community organizations could facilitate comprehensive and culturally tailored interventions. reducing the marketing of unhealthy foods, especially to children and adolescents, is crucial [3]. community initiatives promoting access to healthy, affordable food are needed. increasing public awareness about the health risks of processed foods and the potential for food addiction could motivate special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 11 2024, vol. 4 no. s1 pg. 1-14 change. supporting research on the neurobiological mechanisms of food addiction and developing effective interventions is essential. acknowledgements: nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. funding: funded by dhr health high school and community outreach; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. javed z, valero‐elizondo j, maqsood mh, et al. social determinants of health and obesity: findings from a national study of us adults. obesity. 2022;30(2):491-502. doi:https://doi.org/10.1002/oby.23336 2. rodgers a, woodward a, swinburn b, dietz wh. prevalence trends tell us what did not precipitate the us obesity epidemic. the lancet public health. 2018;3(4):e162e163. doi:https://doi.org/10.1016/s2468-2667(18)30021-5 3. nelson mc, story m, larson ni, neumark-sztainer d, lytle la. emerging adulthood and college-aged youth: an overlooked age for weight-related behavior change. obesity. 2018;16(10):2205-2211. doi:https://doi.org/10.1038/oby.2008.365 4. hauerslev m, narang t, gray n, samuels ta, bhutta za. childhood obesity on the rise during covid‐19: a request for global leaders to change the trajectory. obesity. 2021;30(2). doi:https://doi.org/10.1002/oby.23307 5. white m. food access and obesity. obesity reviews. 2007;8(s1):99-107. doi:https://doi.org/10.1111/j.1467-789x.2007.00327.x 6. polk se, schulte em, furman cr, gearhardt an. wanting and liking: separable components in problematic eating behavior? appetite. 2017;115:45-53. doi:https://doi.org/10.1016/j.appet.2016.11.015 7. calcaterra v, cena h, rossi v, santero s, bianchi a, gian vincenzo zuccotti. ultraprocessed food, reward system and childhood obesity. children. 2023;10(5):804-804. doi:https://doi.org/10.3390/children10050804 8. schulte em, gearhardt an. associations of food addiction in a sample recruited to be nationally representative of the united states. european eating disorders review. 2017;26(2):112-119. doi:https://doi.org/10.1002/erv.2575 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 12 2024, vol. 4 no. s1 pg. 1-14 9. e. miller l, joachim-célestin m, lara m, et al. acculturation, familial support, and unhealthful dietary patterns: evaluating notable trends in a latino population. hphr journal. 2019;(23). doi:https://doi.org/10.54111/0001/w1 10. eskandari f, lake aa, rose k, butler m, o’malley c. a mixed‐method systematic review and meta‐analysis of the influences of food environments and food insecurity on obesity in high‐income countries. food science & nutrition. 2022;10(11). doi:https://doi.org/10.1002/fsn3.2969 11. kim je, tsoh jy. cigarette smoking among socioeconomically disadvantaged young adults in association with food insecurity and other factors. preventing chronic disease. 2016;13. doi:https://doi.org/10.5888/pcd13.150458 12. wattick ra, olfert md, claydon e, hagedorn-hatfield rl, barr ml, brode c. early life influences on the development of food addiction in college attending young adults. eating and weight disorders studies on anorexia, bulimia and obesity. 2023;28(1). doi:https://doi.org/10.1007/s40519-023-01546-3 13. gearhardt an, waller r, jester jm, hyde lw, zucker ra. body mass index across adolescence and substance use problems in early adulthood. psychology of addictive behaviors. 2018;32(3):309-319. doi:https://doi.org/10.1037/adb0000365 14. janssen hg, davies ig, richardson ld, stevenson l. determinants of takeaway and fast food consumption: a narrative review. nutrition research reviews. 2017;31(1):16-34. doi:https://doi.org/10.1017/s0954422417000178 15. pan a, malik vs, hu fb. exporting diabetes mellitus to asia. circulation. 2012;126(2):163-165. doi:https://doi.org/10.1161/circulationaha.112.115923 16. gidding ss, lichtenstein ah, faith ms, et al. implementing american heart association pediatric and adult nutrition guidelines. circulation. 2009;119(8):1161-1175. doi:https://doi.org/10.1161/circulationaha.109.191856 17. poti jm, braga b, qin b. ultra-processed food intake and obesity: what really matters for health—processing or nutrient content? current obesity reports. 2017;6(4):420431. doi:https://doi.org/10.1007/s13679-017-0285-4 18. schulte em, jacques-tiura aj, gearhardt an, naar s. food addiction prevalence and concurrent validity in african american adolescents with obesity. psychology of addictive behaviors. 2018;32(2):187-196. doi:https://doi.org/10.1037/adb0000325 19. pursey km, skinner j, leary m, burrows t. the relationship between addictive eating and dietary intake: a systematic review. nutrients. 2021;14(1):164. doi:https://doi.org/10.3390/nu14010164 20. pursey k, stanwell p, gearhardt a, collins c, burrows t. the prevalence of food addiction as assessed by the yale food addiction scale: a systematic review. nutrients. 2014;6(10):4552-4590. doi:https://doi.org/10.3390/nu6104552 21. gordon e, ariel-donges a, bauman v, merlo l. what is the evidence for “food addiction?” a systematic review. nutrients. 2018;10(4):477. doi:https://doi.org/10.3390/nu10040477 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 13 2024, vol. 4 no. s1 pg. 1-14 22. wiss da, avena n, gold m. food addiction and psychosocial adversity: biological embedding, contextual factors, and public health implications. nutrients. 2020;12(11):3521. doi:https://doi.org/10.3390/nu12113521 23. mason sm, flint aj, field ae, austin sb, rich-edwards jw. abuse victimization in childhood or adolescence and risk of food addiction in adult women. obesity. 2013;21(12):e775-e781. doi:https://doi.org/10.1002/oby.20500 24. cummings jr, schiestl et, tomiyama aj, mamtora t, gearhardt an. highly processed food intake and immediate and future emotions in everyday life. appetite. 2022;169:105868. doi:https://doi.org/10.1016/j.appet.2021.105868 25. li js, barnett ta, goodman e, wasserman rc, kemper ar. approaches to the prevention and management of childhood obesity: the role of social networks and the use of social media and related electronic technologies. circulation. 2013;127(2):260267. doi:https://doi.org/10.1161/cir.0b013e3182756d8e 26. eneli iu, crum pa, tylka tl. the trust model: a different feeding paradigm for managing childhood obesity. obesity. 2008;16(10):2197-2204. doi:https://doi.org/10.1038/oby.2008.378 27. kavle ja, mehanna s, saleh g, et al. exploring why junk foods are “essential” foods and how culturally tailored recommendations improved feeding in egyptian children. maternal & child nutrition. 2014;11(3):346-370. doi:https://doi.org/10.1111/mcn.12165 28. sand as, emaus n, lian os. motivation and obstacles for weight management among young women – a qualitative study with a public health focus the tromsø study: fit futures. bmc public health. 2017;17(1). doi:https://doi.org/10.1186/s12889-017-4321-9 29. fuster v, voute j, hunn m, smith sc. low priority of cardiovascular and chronic diseases on the global health agenda. circulation. 2007;116(17):1966-1970. doi:https://doi.org/10.1161/circulationaha.107.733444 30. duran ac, mialon m, crosbie e, et al. food environment solutions for childhood obesity in latin america and among latinos living in the united states. obesity reviews. 2021;22(s3). doi:https://doi.org/10.1111/obr.13237 31. basu t, ujala sehar, selman a, reddy ap, p. hemachandra reddy. support provided by caregivers for community-dwelling obesity individuals: focus on elderly and hispanics. healthcare. 2023;11(10):1442-1442. doi:https://doi.org/10.3390/healthcare11101442 32. navarro-prado s, schmidt-riovalle j, ángel fernández-aparicio, miguel ángel montero-alonso, perona js, gonzález-jiménez e. assessing the impact of religion and college life on consumption patterns of ultra-processed foods by young adults: a cross-sectional study. nutrients. 2024;16(11):1619-1619. doi:https://doi.org/10.3390/nu16111619 33. ares g, antúnez l, alcaire f, vidal l, bove i. listening to the voices of adolescents for the design of strategies to promote healthy eating: an exploratory study in a latin special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.1 dhr proceedings ǀ http://dhrproceedings.org 14 2024, vol. 4 no. s1 pg. 1-14 american country. public health nutrition. 2021;24(17):5953-5962. doi:https://doi.org/10.1017/s1368980021002548 34. wen lm, rissel c, he g. the effect of early life factors and early interventions on childhood overweight and obesity. journal of obesity. 2015;2015:1-2. doi:https://doi.org/10.1155/2015/964540 35. hung tkw, dong ts, chen z, et al. understanding the heterogeneity of obesity and the relationship to the brain-gut axis. nutrients. 2020;12(12):3701. doi:https://doi.org/10.3390/nu12123701 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 61 2023, vol. 2 no. s2 61-70 commentary the effects of nicotine vaping on high schoolers in south texas adhira tippur1,2, julia martinez1,3, ricardo escobedo1,4, esmeralda guevara1,5, daisy de leon1,5, frida aguilar1,6, brittney grimaldo1,7, kaeli castillo1,7, annasophia castillo1,8 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 mathematics and science academy at the university of texas rio grande valley, edinburg, tx 3 mcallen high school, mcallen, tx 4 psja collegiate school of health professions, san juan, tx 5 edcouch-elsa high school, edcouch, tx 6 jubilee brownsville, brownsville, tx 7 united south high school 8 idea pharr college preparatory, pharr, tx received: august 3, 2023 accepted for publication: november 3, 2023 published: november 16, 2023 introduction ironically, vaping was created as an aid to help stop smoking, but it continues to give its users the same life threatening effects that cigarettes have.1 it seduces its victims with the thousands of different enticing flavors and a false perception that it won’t negatively affect your body. the new habit that vaping has become is far from harmless and is becoming a dangerous addiction.1 this epidemic is booming in the pediatric and youth population since they are being targeted as new consumers instead of what the device was originally intended for, smoking cessation. it has become so normalized that in a monitoring the future survey, it was shown that 40% of high school seniors had used it within the past year.2 the advancements in e-cigarettes retracted the progress that was made in decreasing nicotine in our youth population for the past 5 decades. vaping has become 2 to 3 times more prevalent in adolescents compared to young adults.3 this epidemic brings every user some sort of compromise to their health, and since they are starting younger, their addiction will last longer leaving their body weaker in the end.3 vaping may seem like a harmless act but it can extremely affect your life. in the wake of this escalating crisis, it is crucial to recognize that every user, irrespective of age, confronts a compromise to their health. despite recent federal efforts to mitigate youth exposure to ecigarettes, a pressing need remains for more stringent regulations governing the sale and marketing of these products. coupled with the imperative development of robust educational, clinical, and public health interventions, this collective approach holds the potential to stem the burgeoning tide of what has become an unprecedented nicotine epidemic among our youth. while the act of vaping may outwardly appear benign, the profound impact it can exert on an individual's life should not be underestimated. in light of the mounting evidence, it becomes evident that the allure of vaping conceals a perilous reality. history nicotine vapes were developed in the 1990’s when the first patents for e-cigarettes containing nicotine were filed by tobacco companies and inventors. in 2003, the first commercialized ecigarette hit the market; it was made by a 52 year old pharmacist, hon lik, sold primarily in china.4 in august of 2006, u.s. customs and border protections filed the first nicotine inhaler imports.4,5 three years later, the food and drug administration instructed the u.s. customs and border protection to deny the entry special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 62 2023, vol. 2 no. s2 61-70 of electronic cigarette imports due to their drug-like nature.6 recently popularized, the juul vape pen was created in 2015 with the goal of having more nicotine delivered to the user. with juul’s success, more and more companies have developed their own nicotine ecigarettes and have continuously marketed them towards younger ages. there are now 460+ different brands with 7700+ different flavors.7,8 forward to 2019, then u.s. president donald trump amended the legislation of the federal food, drug, and cosmetic act that raised the federal minimum age of 18 to 21 in the sale of tobacco products, including e-cigarettes.9 however, that did not stop vaping from getting more popular within the youth population. prevalence the prevalence of e-cigarette utilization has notably surged among young adults, drawing attention to a pressing public health concern. notably, between 2019 and 2020, sales of e-cigarettes witnessed a dramatic upswing.10 moreover, the period spanning 2017 to 2019 witnessed a discernible escalation in cannabis-associated vaping, particularly marked among adolescents from low socioeconomic hispanic/latino backgrounds.11 this trend is underscored by a specific statistic: a significant increase in vaping rates among high school seniors, with 37.3% reporting usage within the past year, as compared to 27.8% in 2017.12 the conspicuous escalation of e-cigarette usage within this demographic has reached a critical juncture, assuming the proportions of an epidemic. in fact, there has been a consequential surge in vapinginduced lung injuries across the united states.13 tragically, this surge in usage has caused numerous fatalities, with a disproportionate number occurring among teenagers.14 these e-cigarette products, recognized for their elevated nicotine content, exercise a particularly strong allure over young adults10 evidently, certain regions, including texas, wisconsin, and illinois, have registered alarmingly high mortality rates linked to vaping.15 moreover, the ramifications extend beyond immediate fatalities, as vaping has been linked to an array of adverse health effects, most notably its association with lung cancer. given that lung cancer stands as the foremost contributor to cancer-related mortalities, the imperative to curtail these figures becomes even more pronounced.16 although tobacco smoke remains the leading etiological factor, the significant contribution of vaping to the prevalence of lung cancer cannot be undermined. data by races in our community in the state of texas, a significant proportion of high school students, approximately 18.3%, are engaged in vaping nicotine. notably, in south texas, the odds of high school hispanics and whites engaging in vaping are 2.5-3 times greater than those of any other ethnicity or age group.17 over the past five years, the utilization of nicotine has experienced a rapid upsurge, particularly with the emergence of covid19. this increase has been so substantial that the prevalence of nicotine use among students has escalated from 1.5% in 2011 to 20.3% in 2018.18 with the onset of the covid-19 pandemic in south texas and subsequent quarantine measures, a considerable number of adolescents turned to vaping as a means of "escaping" the real world, resulting in a swift progression towards addiction. shockingly, within the last month alone, around 14.1% of students, which equates to roughly 2 million individuals in south texas, have reported using nicotine products.19 amongst teenagers, nicotine consumption has witnessed the most significant growth over the past five years. moreover, approximately 43.4% of teens in south texas are grappling with depression and/or anxiety, factors that could potentially contribute to their engagement with substances like nicotine.18 the escalating trend of vaping in teens is a cause for concern that requires prompt attention and intervention. figure 1: representation of teens using nicotine.19 types of vape pens the following are vape pens that contain nicotine, either salt-based nicotine or freebase nicotine.21 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 63 2023, vol. 2 no. s2 61-70 ● all in one (aio): this device comes with a built-in battery and refillable tank containing a substance named e-liquids. the idea behind how nicotine is contained in e-liquids in vapes is that it may exist in the form of scattered particles ranging in nicotine concentrations.23 ● mods: vape pens classified as mods are made for the user to be able to modify the levels of freebase nicotine that will be inhaled to reduce irritation from the usage.21 ○ pod mods: a common brand known as juul, is known to have the highest percentage of nicotine usage, 80.3% followed by cig-alikes with 51.4%.22 marketing strategies for juul has been used to create the verb “juuling” instead of vaping. this branding makes it seem less dangerous and differentiates this pen from the others by containing prefilled pod cartridges.22 ○ box mods: these are a more advanced type of vape, with more complex settings, giving more options on the nicotine concentrations that are consumed.22 they also contain a bigger battery for longer hour duration, along with other settings that control temperature and wattage. ● cig-a-likes: these have a significant figure that resembles a typical cigar. however, since these devices are electronic, they are categorized as e-cigarettes. this type of pen usually comes pre-filled with its own nicotine containing e-liquid. ● pen-style vape pens: these devices are known to be the most “under the radar” vape pens, as they don’t look as suspicious as others. however, they still contain the same functions as other mods with bigger, newer models. juul and pod mods have a greater nicotine dependence and are the most used by youth.24 as a result of the variety of models available, it makes it easier for the high school population to carry them around without calling too much attention to themselves. figure 2: various types of vape pens.1 general effects of nicotine vaping the impact of nicotine vaping unfolds insidiously, often going unnoticed by users. yet, its consequences can swiftly accelerate, yielding harm that may remain unrecognized. a comprehensive overview of the overarching facets of the various underlying causes is of paramount significance, for these latent triggers possess the potential to evolve into adverse effects in the human body. if the awareness is low on the effects of nicotine vaping, the greater the risk of experiencing the repercussions of vaping. within this intricate web of effects, a cascade of physiological disruptions emerges, spanning respiratory impairments, cardiovascular anomalies, immune system deviations, and the insidious grip of addiction. additionally, the pervasive influence of nicotine vaping casts a shadow over cognitive maturation, with repercussions palpably reverberating through brain development, impacting academic achievement, and ultimately yielding profound social consequences.25 to fully comprehend the intricate tapestry of repercussions borne from nicotine vaping, an exploration into each facet is imperative, uncovering a comprehensive panorama of the toll it exacts upon the individual and society as a whole. respiratory system the integrity of our respiratory system is paramount to our existence. unfortunately, the act of nicotine vaping poses a substantial risk to the wellbeing of our lungs, potentially culminating in dire afflictions such as chronic obstructive pulmonary disease (copd) and lung cancer.26 the indispensable role of our lungs in the everyday act of breathing renders them vulnerable to the deleterious influence of nicotine vaping. compelling research underscores the special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 64 2023, vol. 2 no. s2 61-70 deleterious impact of vaping on our respiratory health, manifesting in symptoms like dyspnea, persistent coughing, and debilitating chest pain.27 to illustrate, the act of coughing serves as a natural mechanism through which our lungs expel foreign substances, acting as a protective barrier against harm. however, this defense mechanism is compromised in the face of nicotine vaping, as the harmful effects disrupt the harmonious functioning of our respiratory system, thwarting its ability to safeguard our well-being. cardiovascular system the intricate nature of the cardiovascular system, also referred to as the circulatory system, forms a fundamental pillar of the human anatomy, encompassing blood circulation, oxygen dissemination, nutrient conveyance, and an array of indispensable operations.28 in the context of nicotine vaping, the very underpinnings of this intricate network confront heightened vulnerability, potentially exposing it to adverse outcomes. a comprehensive investigation underscored the profound repercussions of nicotine, unveiling a cascade of deleterious effects. evident among these are elevated systolic and diastolic blood pressure, acceleration in heart rate, and pronounced arterial rigidity, collectively exerting a constricting influence upon the optimal functioning of the cardiovascular ensemble.29 the intricate balance of homeostatic mechanisms within the circulatory system undergoes discernible alterations upon exposure to nicotine, characterized by inflammation and subatomic perturbations.30 the consequences underscore the imperative of safeguarding cardiovascular health in the face of nicotine-mediated perturbation. immune system the immune system serves as a vital shield, safeguarding the human body against pathogens, diseases, and bacterial threats that could potentially induce illness. a deficiency in this protective mechanism increases susceptibility to germs and viruses, subsequently exacerbating health complications. notably, the potency of the immune system wanes with age, rendering individuals more vulnerable to potential health risks.31 the perturbing reality emerges that nicotine vaping, replete with its toxic constituents, exerts a pernicious influence on the immune system. this unsettling nexus becomes particularly pronounced among adolescents who embrace nicotine vaping, a demographic vulnerable to the gradual erosion of their immune defenses.32 consequently, the burgeoning prevalence of teen nicotine vaping poses a substantive concern, as it threatens to undermine their immune resilience over time. addiction when nicotine binds to specific receptors in the brain, it leads to the release of different chemicals, with dopamine being the most significant among them.33 this release of dopamine in the brain's ventral tegmental area and the shell of the nucleus accumbens is crucial in causing the rewarding effects of nicotine and other drugs.33 this includes feeling pleasure, which reinforces the desire to use them again. the reinforcement of pleasure associated with vaping quickly establishes a cycle of dependence.33 when humans experience nicotine withdrawal, their brain's reward system decreases. this occurs because of a lack of dopamine being released, which results in a reduced feeling of pleasure.34 given these circumstances, quitting vaping becomes extremely difficult. according to a 2020 report, 5.47% of teens reported unsuccessful attempts to quit vaping.35 nicotine addiction can manifest differently from person to person. some signs of nicotine addiction may include feeling anxious, experiencing strong cigarette cravings, or going out of your way to buy it.36 after quitting nicotine use, individuals who are addicted may also encounter symptoms of nicotine withdrawal, such as feeling depressed or experiencing difficulty sleeping properly.36 brain development throughout the teenage years, the brain continues to grow, and nicotine use during this crucial time can have a variety of negative effects. genetic studies have shown how nicotine plays a role in how we learn and develop dependence.33 nicotinic acetylcholine receptors (nachrs) are found in both central and peripheral nervous systems.36 when a molecule known as ligand attaches to these receptors, they function as tiny gates that open.36 the neuronal nachr subunits are made up of α-2 to α-10 subunits and β-2 to β-4 subunits.37 although these receptors bind to acetylcholine naturally, other molecules such as nicotine can stick to them.38 notably, nicotine easily binds to α-4 and β-2 nachrs, unlike other receptors.33 as teens grow and their brains develop, nicotine exposure can impact the nachr receptors in their brain, modify dopamine sensitivity, and alter brain circuits that influence learning, stress responses, and self-control.36 it may also result in outcomes that affect the brain's reward system, which involves the special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 65 2023, vol. 2 no. s2 61-70 prefrontal cortex, nucleus accumbens, ventral tegmental area, hippocampus, and basolateral amygdala.39 this can involve addiction and dependence, as well as withdrawal symptoms when not consuming nicotine.36 these developing brains are at risk of lasting changes from perturbations that result in changes in behavior that continue into adulthood.39 academic performance vaping nicotine can have negative effects on teenagers, primarily because they are susceptible to influence. many teens start vaping due to peer pressure, seeking acceptance and fitting into societal norms.40 with the availability of various flavors in vaping products, many teenagers tend to be attracted to them.40 while electronic cigarettes may provide pleasure through dopamine release, they can also negatively impact students' academic performance. nicotine's interference with cognitive functions can make it difficult to focus and recall knowledge.36 as a result, teens can find it difficult to concentrate in class, which could affect their grades. teenagers are also more likely to skip class or engage in academic dishonesty due to the effects of nicotine on the brain's prefrontal cortex, which regulates their thoughts and behaviors.39 notably, vaping nicotine can cause respiratory issues that can prevent a student from attending lessons.36 the student will likely miss numerous school days due to the importance of attending multiple doctor's appointments to address this health concern. this situation could potentially lead to them being held back a year. with these problems also comes depression, which can cause the person to lose interest in and care less about school.36 nonetheless, vaping nicotine can result in restlessness, which would make the learner less alert and tired.36 social consequence among the various possible consequences a vaping teen could inflict, is pressuring their peers into pursuing the need to vape nicotine. when teens have their ‘first vape session’, they were likely pressured into having tried vaping by their friends.41 seeing that a lot of teens vape this can affect groups of friends by dividing them between those who vape and those who don’t. from these now separated friend groups they enjoy playing a ‘cat and mouse’ game at school to see who doesn’t get caught vaping.40 as a teen starts to feel detached from their family, an outsider, they tend to look at vaping as a way to not feel their loneliness.42 nicotine gives its user various side effects; such as, mood swings, impaired impulse control, and increased anxiety, all of which cause the user to feel different leading them to withdraw from their family and friends.42 in romantic relationships, when one of them vapes and the other doesn’t it can lead to disagreements. in these situations it can lead to added stress and tension to a relationship that was possibly a happy one in the beginning. vaping can have people start breaking down their trust, lying about vaping can lead to an added strain on a relationship coming from dishonesty. these different instances likely come about from the prevalence of people vaping in their social circle.40 figure 2: effects of vaping on human health. created with biorender.com. policies and regulations enforcing stringent regulations is imperative to effectively mitigate the proliferation and accessibility of vaping devices. the pervasive exposure of vaping advertisements to children and adolescents, often through easily accessible mediums such as social media, underscores a concerning trend.43 this demographic is particularly susceptible to environmental influences, rendering them more susceptible to the allure of these campaigns, even as purported alternatives to traditional cigarette smoking.44 notably, numerous vaping advertisements feature characters and themes that conspicuously cater to a younger audience, accentuating the need to acknowledge the strategic targeting of these ads.45 the strategic placement and marketing techniques employed hold significant sway over the purchasing decisions of teenagers, warranting heightened attention.46 several nations, including india since 2019, have taken a resolute stance by prohibiting the marketing and sales of vaping products.47 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 66 2023, vol. 2 no. s2 61-70 furthermore, the efficacy of specific regulatory measures has been demonstrated in curbing vaping and tobacco consumption. notably, the imposition of taxes on such products has effectively diminished their allure, thereby reducing demand.3 this insight substantiates the proposition of implementing additional taxes on vaping products across all states, serving to curtail their prevalence and concurrently channel funds into vital research aimed at preventing nicotine addiction among adolescents. a seminal study investigating the impact of the truth initiative campaign on vaping-related choices revealed a marked reduction in tobaccorelated beliefs and overall support for vaping, especially among african american youth followed by white and hispanic counterparts.48 this campaign's resonance with the youth is an encouraging stride, though further research is imperative to gauge its lasting effectiveness. conversely, disconcerting findings highlight a glaring lack of due diligence by companies in verifying the age of purchasers, with a staggering 95% of deliveries failing to implement any form of age verification.49 this laxity extends to online platforms, where minimal regulations allow unfettered access to vaping devices, often exploited by adolescents.50 even establishments that impose age restrictions exhibit lapses in enforcement, contributing to the ease with which high school students acquire these harmful products, thereby exposing them prematurely to the perils of nicotine addiction. a potent recommendation to mitigate this crisis involves reducing the prevalence of websites neglecting age restrictions and enforcing punitive measures against those in contravention.3 this approach envisages a multi-pronged strategy, encompassing regulatory fines and penalties, to dissuade non-compliance and foster a safer environment for adolescents. by harmonizing stringent regulations, targeted interventions, and sustained research endeavors, a comprehensive framework can be established to safeguard the vulnerable youth from the detrimental consequences of vaping. prevention of nicotine addiction parents wield significant influence over their children's decisions throughout their developmental journey. extensive research underscores that adolescents who experience consistent respect and unwavering support exhibit diminished propensities for substance abuse encompassing drugs, smoking, and alcohol when contrasted with their counterparts lacking such nurturing conditions.51 in pursuit of curtailing adolescent vaping, a contemporary concern, parental intervention strategies can be strategically employed. exemplify prudent behavior parents serve as pivotal role models in their children's lives, and by refraining from smoking, parents inherently diminish the allure of this behavior for their offspring. foster open discourse engaging in candid conversations with adolescents about the physiological risks associated with vaping and smoking is imperative. sustaining such dialogue over time, while embracing your child's perspective, remains crucial even as they transition into later stages of adolescence. prepare youth against peer pressure equipping your children with informed responses and actions to counter potential offers of vaping or cigarette usage from peers is vital, thereby empowering them to make sound decisions in challenging social situations. incorporating these preventive measures within the parental sphere not only bolsters the prospects of deterring adolescent vaping but also establishes a foundation for comprehensive healthoriented decision-making.52 nicotine addiction treatment in instances where nicotine addiction has taken hold and necessitates intervention, an array of treatments stands poised to address this challenge. these treatment modalities can be thoughtfully combined and are viable options for individuals under the age of 18, albeit requiring a health professional's prescription to commence. nicotine replacement therapy (nrt) nrt emerges as a cornerstone, offering an enhanced likelihood of efficacious outcomes by combating smoking cravings. within this domain, nicotine patches command a notable 50 to 60 percent special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 67 2023, vol. 2 no. s2 61-70 efficacy compared to alternative interventions.53 available in strengths of 7mg, 14mg, and 21mg, patch selection hinges upon current smoking habits.54. typically worn for 24 hours on clean, hair-free skin, precise placement on the upper body aligns with manufacturer guidelines. nicotine gum, having a 15 to 20 % effectiveness, holds promise for those who sustain its use for a year or beyond.55 this therapeutic option presents in 2mg and 4mg dosages, contingent upon the temporal patterns of habitual cigarette consumption.56 the nicotine lozenge surfaces as another viable recourse, progressively demonstrating its potential to amplify smoking cessation prospects.57 offered in standard and mini sizes (2mg and 4mg), dosage determination hinges on the quantum of daily nicotine intake.58 prescription medications further options encompass prescribed medications, necessitating the authorization of a medical practitioner.59 notably, bupropion, initially an antidepressant, has evolved to counter nicotine cravings with positive results.60 it is paramount to reiterate that all intervention avenues should remain under the vigilant oversight of a medical expert, affording both safety and optimal chances of success. this comprehensive approach underscores the commitment to comprehensively combatting nicotine addiction and fostering enduring well-being. conclusion a proliferation of vaping among high school students has culminated in an alarming epidemic, characterized by staggering numbers that underscore its gravity. this phenomenon, however ironic, reveals a disheartening truth: vaping, initially designed to curtail smoking addictions, now surpasses traditional smoking in its adverse impact on the human body. the proliferation of vaping among high school students has culminated in an alarming epidemic, characterized by staggering numbers that underscore its gravity. an unfortunate consequence of this burgeoning crisis is the surge in injuries and fatalities among high school users. an intricate interplay of cardiovascular, respiratory, and cognitive effects contributes to the escalating toll inflicted by vaping. high school students under the age of 21 should not be able to acquire vapes due to the federal law. despite federal legislation stipulating an age requirement of 21 for vape purchases, the prevalence of access within high schools remains a disconcerting norm, facilitated by clandestine transactions among students during and after school hours. this trade is exacerbated by the camouflage of vaping devices as everyday objects, further evading detection by vigilant educators. a staggering statistic emerges from texas, where an accelerating 18.3% of high school students have embraced vaping. this surge is partially attributed to advertising strategies that conspicuously target impressionable teenagers, compelling them to partake in this perilous practice. even with age restrictions in place, certain vape vendors prioritize profit over ethical considerations, willingly selling to underage clientele. mitigating this crisis necessitates a multifaceted approach. education emerges as a powerful tool, empowering children with knowledge to make informed decisions. prescribed medications, nicotine gum, and patches offer potential avenues for treatment. the collective effort to disseminate awareness, alongside these prevention and treatment measures, kindles hope for a future where the tide of vaping recedes, inching us closer to its eventual eradication. looking into the future, armed with an arsenal of interventions, heightened awareness, and collaborative endeavors, the prospect of diminishing these disconcerting statistics comes into view, fostering the aspiration of ultimately vanquishing vaping's grip on our youth. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. dinardo p, rome es. vaping: the new wave of nicotine addiction. cleveland clinic journal of medicine. 2019;86(12):789-798. doi: 10.3949/ccjm.86a.19118 2. overbeek dl, kass ap, chiel le, boyer ew, casey amh. a review of toxic effects of electronic cigarettes/vaping in adolescents and young adults. crit rev toxicol. 2020;50(6):531-538. doi:10.1080/10408444.2020.1794443 3. chadi n, hadland se, harris sk. understanding the implications of the special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 68 2023, vol. 2 no. s2 61-70 "vaping epidemic" among adolescents and young adults: a call for action. subst abus. 2019;40(1):7-10. doi:10.1080/08897077.2019.1580241 4. casaa. history of vaping historical timeline of events. casaa. published 2020. https://casaa.org/education/vaping/historical -timeline-of-electronic-cigarettes/ 5. cross customs rulings online search system. rulings.cbp.gov. https://rulings.cbp.gov/search?term=m85579 &collection=all&sortby=relevance& pagesize=30&page=1 6. united states district court for the district of columbia. smoking everywhere. https://casaa.org/wp-content/uploads/se-vfda-fda-memo-in-opposition-filed-05-112009.pdf 7. huang j, duan z, kwok j, et al. vaping versus juuling: how the extraordinary growth and marketing of juul transformed the us retail e-cigarette market. tobacco control. 2018;28(2):146-151. doi: 10.1136/tobaccocontrol-2018-054382 8. zhu sh, sun jy, bonnevie e, et al. four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. tobacco control. 2014;23(suppl 3):iii3-iii9. doi: 10.1136/tobaccocontrol-2014-051670 9. center for tobacco products. legislation raises minimum age of sale of tobacco products to 21. u.s. food and drug administration. published 2020. https://www.fda.gov/tobacco-products/ctpnewsroom/newly-signed-legislation-raisesfederal-minimum-age-sale-tobaccoproducts-21 10. leventhal am, dai h, barrington-trimis jl, tackett ap, pedersen er, tran dd. disposable e-cigarette use prevalence, correlates, and associations with previous tobacco product use in young adults. nicotine tob res. 2022;24(3):372-379. doi:10.1093/ntr/ntab165 11. keyes km, kreski nt, ankrum h, et al. frequency of adolescent cannabis smoking and vaping in the united states: trends, disparities and concurrent substance use, 2017-19. addiction. 2022;117(8):23162324. doi:10.1111/add.15912 12. besaratinia a, tommasi s. vaping epidemic: challenges and opportunities. cancer causes control. 2020;31(7):663-667. doi:10.1007/s10552-020-01307-y 13. cherian sv, kumar a, estrada-y-martin rm. e-cigarette or vaping productassociated lung injury: a review. am j med. 2020;133(6):657-663. doi:10.1016/j.amjmed.2020.02.004 14. almeida-da-silva clc, matshik dakafay h, o'brien k, montierth d, xiao n, ojcius dm. effects of electronic cigarette aerosol exposure on oral and systemic health. biomed j. 2021;44(3):252-259. doi:10.1016/j.bj.2020.07.003 15. cao dj, aldy k, hsu s, et al. review of health consequences of electronic cigarettes and the outbreak of electronic cigarettes, or vaping, product useassociated lung injury. j med toxicol. 2020;16(3):295-310. doi:10.1007/s13181020-00772-w 16. bracken-clarke d, kapoor d, baird am, et al. vaping and lung cancer a review of current data and recommendations. lung cancer. 2021;153:11-20. doi:10.1016/j.lungcan.2020.12.030 17. mattingly dt, patel a, hirschtick jl, fleischer nl. sociodemographic differences in patterns of nicotine and cannabis vaping among us adults. prev med rep. 2022;26:101715. published 2022 jan 27. doi:10.1016/j.pmedr.2022.101715 18. fadus mc, smith tt, squeglia lm. the rise of e-cigarettes, pod mod devices, and juul among youth: factors influencing use, health implications, and downstream effects. drug alcohol depend. 2019;201:85-93. doi:10.1016/j.drugalcdep.2019.04.011 19. gandelman ja, newhouse p, taylor wd. nicotine and networks: potential for enhancement of mood and cognition in latelife depression. neurosci biobehav rev. 2018;84:289-298. doi:10.1016/j.neubiorev.2017.08.018 20. wein h. vaping rises among teens. nih news in health. published march 8, 2019. https://newsinhealth.nih.gov/2019/02/vaping -rises-among-teens 21. centers for disease control and prevention. e-cigarette, or vaping, products visual dictionary. https://www.cdc.gov/tobacco/basic_informat ion/e-cigarettes/pdfs/ecigarette-or-vapingproducts-visual-dictionary-508.pdf 22. krishnan-sarin s, jackson a, morean m, et al. e-cigarette devices used by high-school youth. drug alcohol depend. 2019;194:395400. doi:10.1016/j.drugalcdep.2018.10.022 23. miller dr, buettner-schmidt k, orr m, rykal k, niewojna e. a systematic review of refillable e-liquid nicotine content accuracy. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 69 2023, vol. 2 no. s2 61-70 j am pharm assoc (2003). 2021;61(1):2026. 24. tackett ap, hébert et, smith ce, et al. youth use of e-cigarettes: does dependence vary by device type?. addict behav. 2021;119:106918. 25. seiler-ramadas r, sandner i, haider s, grabovac i, dorner te. health effects of electronic cigarette (e‑cigarette) use on organ systems and its implications for public health. wien klin wochenschr. 2021;133(1920):1020-1027. 26. gotts je, jordt se, mcconnell r, tarran r. what are the respiratory effects of ecigarettes? [published correction appears in bmj. 2019 oct 15;367:l5980]. bmj. 2019;366:l5275. published 2019 sep 30. doi:10.1136/bmj.l5275 27. e-cigarette, or vaping product, use associated lung injury (evali). yale medicine. https://www.yalemedicine.org/conditions/ev ali#:~:text=evali%20is%20a%20serious% 20medical 28. chaudhry r, miao jh, rehman a. physiology, cardiovascular. pubmed. published 2020. https://www.ncbi.nlm.nih.gov/books/nbk4 93197/#:~:text=the%20purpose%20of%20t he%20cardiovascular 29. mcgrath-morrow sa, gorzkowski j, groner ja, et al. the effects of nicotine on development. pediatrics. 2020;145(3):e20191346. doi:10.1542/peds.2019-1346 30. echeagaray o, savko c, gallo a, sussman m. cardiovascular consequences of vaping. curr opin cardiol. 2022;37(3):227-235. doi:10.1097/hco.0000000000000952 31. müller l, di benedetto s, pawelec g. the immune system and its dysregulation with aging. subcell biochem. 2019;91:21-43. doi:10.1007/978-981-13-3681-2_2 32. han sg, sillé fcm, mihalic jn, rule am. the relationship between the use of electronic nicotine delivery systems (ends) and effects on pulmonary immune responses—a literature review. environmental research. 2023;221:115234. doi:https://doi.org/10.1016/j.envres.2023.11 5234 33. benowitz nl. pharmacology of nicotine: addiction, smoking-induced disease, and therapeutics. annu rev pharmacol toxicol. 2009;49:57-71. doi:10.1146/annurev.pharmtox.48.113006.0 94742 34. zhang l, dong y, doyon wm, dani ja. withdrawal from chronic nicotine exposure alters dopamine signaling dynamics in the nucleus accumbens. biol psychiatry. 2012;71(3):184-191. doi:10.1016/j.biopsych.2011.07.024 35. e-cigarettes may complicate teen attempts to quit nicotine. national institutes of health (nih). published april 25, 2022. https://www.nih.gov/news-events/nihresearch-matters/e-cigarettes-maycomplicate-teen-attempts-quitnicotine#:~:text=in%20addition%2c%204.1 2%25%20reported%20unsuccessful 36. valentine g, sofuoglu m. cognitive effects of nicotine: recent progress. curr neuropharmacol. 2018;16(4):403-414. doi:10.2174/1570159x15666171103152136 37. brunzell dh, stafford am, dixon ci. nicotinic receptor contributions to smoking: insights from human studies and animal models. curr addict rep. 2015;2(1):33-46. doi:10.1007/s40429-015-0042-2 38. gotti c, clementi f. neuronal nicotinic receptors: from structure to pathology. prog neurobiol. 2004;74(6):363-396. doi:10.1016/j.pneurobio.2004.09.006 39. ren m, lotfipour s. nicotine gateway effects on adolescent substance use. west j emerg med. 2019;20(5):696-709. published 2019 aug 20. doi:10.5811/westjem.2019.7.41661 40. dubé ce, pbert l, nagawa cs, simone dp, wijesundara jg, sadasivam rs. adolescents who vape nicotine and their experiences vaping: a qualitative study. subst abuse. 2023;17:11782218231183934. published 2023 jun 28. doi:10.1177/11782218231183934 41. groom al, vu tt, landry rl, et al. the influence of friends on teen vaping: a mixed-methods approach. int j environ res public health. 2021;18(13):6784. published 2021 jun 24. doi:10.3390/ijerph18136784 42. lyzwinski ln, naslund ja, miller cj, eisenberg mj. global youth vaping and respiratory health: epidemiology, interventions, and policies. npj prim care respir med. 2022;32(1):14. published 2022 apr 11. doi:10.1038/s41533-022-00277-9 43. hatsukami dk, carroll dm. tobacco harm reduction: past history, current controversies and a proposed approach for the future. prev special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.91 dhr proceedings ǀ http://dhrproceedings.org 70 2023, vol. 2 no. s2 61-70 med. 2020;140:106099. doi:10.1016/j.ypmed.2020.106099 44. struik ll, werstuik st, sundstrom a, dowfleisner s, ben-david s. factors that influence the decision to vape among indigenous youth. bmc public health. 2022;22(1):641. published 2022 apr 2. doi:10.1186/s12889-022-13095-y 45. biglan a, van ryzin m, westling e. a public health framework for the regulation of marketing. j public health policy. 2019;40(1):66-75. doi:10.1057/s41271-0180154-8 46. bhave sy, chadi n. e-cigarettes and vaping: a global risk for adolescents. indian pediatr. 2021;58(4):315-319. 47. cowell aj, farrelly mc, chou r, vallone dm. assessing the impact of the national 'truth' antismoking campaign on beliefs, attitudes, and intent to smoke by race/ethnicity. ethn health. 2009;14(1):7591. doi:10.1080/13557850802257715 48. williams rs, derrick j, ribisl km. electronic cigarette sales to minors via the internet. jama pediatr. 2015;169(3):e1563. doi:10.1001/jamapediatrics.2015.63 49. kong g, morean me, cavallo da, camenga dr, krishnan-sarin s. sources of electronic cigarette acquisition among adolescents in connecticut. tob regul sci. 2017;3(1):10-16. doi:10.18001/trs.3.1.2 50. how to keep kids and teens from smoking and vaping. (2022, june 2). www.heart.org. https://www.heart.org/en/healthyliving/healthy-lifestyle/quit-smokingtobacco/how-to-keep-kids-and-teens-fromsmoking-and-vaping 51. how to use nicotine gum | quit smoking | tips from former smokers | cdc. (n.d.). https://www.cdc.gov/tobacco/campaign/tips/ quit-smoking/quit-smokingmedications/how-to-use-quit-smokingmedicines/how-to-use-nicotine-gum.html 52. how to use nicotine lozenges | quit smoking | tips from former smokers | cdc. (n.d.). https://www.cdc.gov/tobacco/campaign/tips/ quit-smoking/quit-smokingmedications/how-to-use-quit-smokingmedicines/how-to-use-the-nicotinelozenge.html#:~:text=do%20not%20use%2 0more%20than,lozenge%20every%204%2d 8%20hours. 53. how to use nicotine patches | quit smoking | tips from former smokers | cdc. (n.d.). https://www.cdc.gov/tobacco/campaign/tips/ quit-smoking/quit-smokingmedications/how-to-use-quit-smokingmedicines/how-to-use-a-nicotine-patch.html 54. mph, s. l. m. (2021a). vaping: it’s hard to quit, but help is available. harvard health. https://www.health.harvard.edu/blog/vaping -its-hard-to-quit-but-help-is-available2019110118248 55. mph, s. l. m. (2021b). vaping: it’s hard to quit, but help is available. harvard health. https://www.health.harvard.edu/blog/vaping -its-hard-to-quit-but-help-is-available2019110118248 56. pack, q. r. (2008, august 1). a comparison of the nicotine lozenge and nicotine gum an effectiveness randomized controlled trial. pubmed central (pmc). https://www.ncbi.nlm.nih.gov/pmc/articles/p mc3174063/#:~:text=both%20the%20nicot ine%20gum%20and%20nicotine%20lozeng e%20are%20fda%2dapproved,%3a%201. 62%20to%202.59)%20respectively. 57. pedersen, t. (2023, july 3). the effectiveness of nicotine patches. healthline. https://www.healthline.com/health/smoking/ do-nicotine-patcheswork#:~:text=the%20nicotine%20patch%2 0demonstrates%20comparable,1%2dyear% 20follow%2dup. 58. thompson, d., jr. (2011, may 9). what you need to know about nicotine gum smoking cessation center. everydayhealth.com. https://www.everydayhealth.com/smokingcessation/nicotine-replacement-therapy.aspx 59. what the science tells us about parenting an adolescent. what the science tells us about parenting an adolescent | center for the developing adolescent. accessed november 15, 2023. https://developingadolescent.semel.ucla.edu/ topics/item/science-about-parentingadolescent#:~:text=research%20into%20pa renting%20styles%20has,parents%20lack% 20either%20warmth%20or. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.88 dhr proceedings ǀ http://dhrproceedings.org 40 2023, vol. 2 no. s2 40-44 commentary the effects of covid-19 on the increasing trend of depression in males diana ballardo1,2, aaliyah coronado1,4, naomi flores1,4, brianna guerrero1,3, cesar hernandez1,2, ramiro moreno1,4, fernanda ortiz1,4, ashely reyes1,3, amelie reyna1,2, rodolfo rodriguez1,3, emilio saucedo1,2, ramiro tijerina1,2 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 1 lyndon b. johnson high school, tx 2 progreso high school, tx 3 hidalgo early college high school, tx received: june 29, 2023 accepted for publication: november 1, 2023 published: november 16, 2023 introduction according to the national institute of mental health, in 2020, approximately 1.3 million males in the united states had at least one major depressive episode.1 major depressive disorder (mdd) is a common and serious mental illness that negatively affects how a person feels, the way they think, and how they act.2 people suffering from depression may experience persistent feelings of sadness, increased apathy towards previously enjoyed pastimes, and even suicidal ideations.2,3 while depression can manifest for a variety of reasons, this paper will focus on the effects of covid-19 (coronavirus disease) on depression in males.4 demographics men are less likely to seek help, be diagnosed, and in turn, be more likely to commit suicide due to untreated depression at a rate four times higher than women.5,6 males are not only at a social but psychological disadvantage because of the stigma that is associated with depression.6 this stigma is based on social constructs, gender roles, stereotypes, and traditional ideologies about masculinity and mental health in men.7 these barriers are usually associated more than anything with the fear of giving the appearance of a weak man, having no self-reliance, and not being in emotional control.7 there is an apparent disparity between male and female rates of depression and should be acknowledged.6 the effect of covid-19 on mental health covid-19 is a mild to moderate respiratory disease that originated in wuhan, china. its primary mode of transmission is through infected respiratory droplets and aerosol particles. most healthy individuals can recover, but those with weakened immune systems can become seriously ill.8,9 during the covid-19 pandemic, the modern world saw just how ill-prepared it was to deal with a highly infectious virus and the deaths that came along with it.10 a world-wide “lockdown” was enacted after covid-19 gained its pandemic status.11,12 in this period, people were only allowed to leave their homes when necessary and social gatherings were banned, limiting the number of people that could be in a confined space at any given time.12 the restrictions placed on people during “lockdown” brings us to the topic of isolation and the role it played in straining the mental health of the general populous.13 isolation in and of itself does not cause depression. the psychological effects of not being able to interact with others make someone more susceptible to depression.14,15 an article published by harvard states how the rates of loneliness in america have risen due, in part, because of the pandemic.16 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.88 dhr proceedings ǀ http://dhrproceedings.org 41 2023, vol. 2 no. s2 40-44 as misinformation became more and more widespread during the pandemic it caused fear to surge among civilians.17 fear can stem from many places but in the case of the covid-19 pandemic, an exponential increase in cases and deaths along with misinformation and constant updates prompted people to become fearful.18 anxiety is a prime catalyst for the prevalence of depression as their symptoms overlap; for example, in the case of gad (general anxiety disorder) and mdd, many of their criteria share similar items such as dyssomnia, fatigue, low concentration, etc.19 in a study published in the journal of affective disorders, doctors and scientists conducted a set of tests called the cdrs-r (children depression rating scale-revised) and pars (pediatric anxiety rating scale) that each looked into both symptoms and severity of illnesses. the study showed how there were many symptoms that either correlated with each other or had some form of effect on each other (figure 1).19 symptoms that fit both disorders included physical complaints, morbid ideation, anhedonia, impaired school work, social withdrawal, and sleep disturbance.19 as a cause of these similarities, the ability of one disorder to transition/develop into the other is more apparent. all throughout the pandemic, there was a spike in not only reported cases but also deaths.19 as of now, the total number of deaths has reached an astronomical high of 1,132,872.20 in many of these deaths, people were directly affected either by the loss of a friend, family member, etc. death, on the occasion of a person dear to you, can have negative effects on not only a person's physical well-being but most of all an individual's mental state. grieving individuals tend to not receive the proper care from psychiatrists whether by misattribution of the symptoms or because of not administering proper care.21 the likelihood of a person acquiring mdd is a lot higher when in the grieving process as they may blame themselves, feel worthless, and have prolonged suicidal ideation.21 this is important to monitor if these symptoms persist after 2 months, as most cases of long-term bereavement are marginal indicators of mdd.21 figure 1(a) figure 1(b) figure 1(a). symptom clusters with grouping via both tests cars-r (black) and pars (white). figure 1(b). symptoms with community analysis clustering, in this instance, the black circles correlate with depressive disorder whilst the white with anxiety. the grey circles had clustering to neither group.19 depression before covid-19 before the covid-19 pandemic, research about men and their mental health was limited, but post-pandemic research on this topic has brought upon a substantial amount of awareness regarding the exclusion of men in the conversation about mental health.22 according to the national center for biotechnology information, males were disregarded psychologically on account to the normalization of gender differences that society has situated amongst the majority of individuals involved. reports show that men with major depressive disorder (mdd) are 2.3% less prevalent than women with mdd over a 12month period.23 on the contrary, this could lead to a common misconception that the results are deemed inaccurate because males are inclined to avoid any form of care provided by doctors. this matter in question revolves primarily around masculinity barriers that many individuals have incorporated such as the lack of financial support and/or care.7 therefore, men seek self-aid instead of professional help that causes worsening of their current situation. the effect of the covid-19 pandemic on depression the covid-19 pandemic phenomenon introduced a new deadly virus worldwide leading to a, similarly, international pandemic requiring countries to fall into a two and a half year lockdown. this virus primarily attacks a person's respiratory system; however, it was found to affect other organ systems such as the cardiac and digestive systems.24 more notably, covid-19 showed significant effects on a patient’s central nervous system as physical manifestations ranging from headaches, encephalitis, convulsions, meningitis, including psychological issues such as depression as a result of chemical special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.88 dhr proceedings ǀ http://dhrproceedings.org 42 2023, vol. 2 no. s2 40-44 imbalances from the virus’ attachment style to ace2 (figure 2).24 persons with a history of mental illnesses suffered repercussions due to the lockdown, as mental health became less of a priority than covid-19 treatment, excising the probability of receiving proper care.25 it became evident that the lack of effective treatment and care played a key role in depressionrelated cases, and in worst-case scenarios, deaths. in the wake of the pandemic came a rise of mental health issues with new light shed and as jim e. wallis states, “sometimes it takes a natural disaster to reveal a social disaster.”25 figure 2. chemical correlation between covid19, sars-cov-2, and its effect on ace-2 throughout the nervous system leading to depression. the sars-cov-2 binds to the body's ace-2 causing an inflammatory response to occur exposing the brain to dysregulation of hormones initiating a person's symptoms of depression.24 impact by age group covid-19 infects individuals across all different demographics, a similar situation can be documented with the event of the “quarantine” process and its association with the increase in depression cases. despite that fact, however, there is considered to be a prevalence in cases among male, young adults. for instance, in a study conducted from april 2020 through february 2021, the increase in cases of mdd was measured through the link of solitude, where many individuals were expected to remain at home or away from others causing many to be alone or cut–off from social interaction, in the cdc recommended social isolation.12 upon further examination, it was deduced that the individuals who were experiencing the most loneliness, which was later revealed to be young adult men, were subject to report 14 times more cases of mdd.26 furthermore, as previously known data states, mdd and its symptoms are more likely to present themselves across a younger age pool.26 thus, this information provides an alignment that is parallel to the finding of its prevalence in young adult males, thereby qualifying the data acquired. figure 3 shows the prevalence of depression symptoms on a global scale with data from a study conducted across 114 different countries measuring depressive symptoms of men of varying age groups. based on the information given, the majority of all countries’ men faced depression to a certain capacity, to which, most of those men were recorded to have a rate of at least 1:4 men having experienced symptoms of depression.27 furthermore, correlating the graph to a specific age range, the study yielded that most of the men who contributed to the study were of ages 18-24 as they expressed symptoms at a greater degree, whereas, when the age increased, the number of depressive symptoms decreased.27 simply put, the research, provided by the british medical journal, gives insight into how the pandemic increased the cases of adult men at large scale. data from both studies indicates the covid-19 pandemic did, in fact, have a frequent effect on the age group of young adult males. as the first conducted study was able to be supported by previous researched data and the second study provided evidence across a significant number of countries, they both served the purpose of proving that covid-19 did not only affect men as whole, but they proved it had a significant influence on young, adult men. figure 3. choropleth map based on a poll of 115 countries from may 2021 to september 2021. the map provides statistics on a global scale to further elucidate the number of men facing feelings of depression. treatments treatments for depression include psychological treatments, therapies and medications. the duration of treatment is divided into 2 phases: acute treatment lasting 6-8 weeks and the continuation treatment lasting from 4-9 months.28 there are also different types of therapy to deal with depression. there is cognitive behavioral therapy and systemic therapy.29 cognitive behavioral therapy focuses on how thoughts and beliefs influence individual actions special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.88 dhr proceedings ǀ http://dhrproceedings.org 43 2023, vol. 2 no. s2 40-44 and systemic therapy focuses more on the relationship with external stimuli, including family and friends.28 antidepressants help relieve the symptoms of depression and include doxepin, dosulepin, citalopram, among others. some medications are short-acting but most are lifestyle medications that require long-term compliance.30 conclusion in review of the research available, there is a direct correlation between the increase in depression cases and the covid-19 pandemic. the overall data found throughout the literature reveals why males were greatly impacted but also how this prevalence came to be. the importance of male depression is an overall dilemma faced by many generations and nationalities. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. national institute of mental health. major depression. national institute of mental health. published january 2022. https://www.nimh.nih.gov/health/statistics/ major-depression 2. torres f. what is depression? american psychiatric association. published october 2020. https://www.psychiatry.org/patientsfamilies/depression/what-is-depression 3. national institute of mental health. depression. national institute of mental health. published april 2023. https://www.nimh.nih.gov/health/topics/depr ession 4. harvard health publishing. what causes depression? harvard health. published january 10, 2022. https://www.health.harvard.edu/mind-andmood/what-causes-depression 5. mayo clinic. behaviors in men that could be signs of depression. mayo clinic. published 2019. https://www.mayoclinic.org/diseasesconditions/depression/in-depth/maledepression/art-20046216 6. chatmon bn. males and mental health stigma. american journal of men’s health. 2020;14(4). doi:https://doi.org/10.1177/1557988320949 322 7. swetlitz n. depression’s problem with men. ama journal of ethics. 2021;23(7):e586589. doi:https://doi.org/10.1001/amajethics.2021. 586 8. who. coronavirus disease (covid-19). world health organization. published 2021. https://www.who.int/healthtopics/coronavirus#tab=tab_1 9. centers for disease control and prevention. coronavirus disease 2019 (covid-19). centers for disease control and prevention. published february 11, 2020. https://www.cdc.gov/coronavirus/2019ncov/science/science-briefs/sars-cov-2transmission.html 10. world health organization. who directorgeneral’s opening remarks at the media briefing on covid-19 11 march 2020. world health organization. published march 11, 2020. https://www.who.int/directorgeneral/speeches/detail/who-directorgeneral-s-opening-remarks-at-the-mediabriefing-on-covid-19---11-march-2020 11. ajmc staff. a timeline of covid-19 developments in 2020. ajmc. published january 2, 2021. https://www.ajmc.com/view/a-timeline-ofcovid19-developments-in-2020 12. cdc museum covid-19 timeline. centers for disease control and prevention. published january 5, 2022. https://www.cdc.gov/museum/timeline/covi d19.html#:~:text=march%2015%2c%2020 20 13. loades me, chatburn e, higson-sweeney n, et al. rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of covid-19. journal of the american academy of child & adolescent psychiatry. 2020;59(11):1218-1239. doi:https://doi.org/10.1016/j.jaac.2020.05.00 9 14. novotney a. the risks of social isolation. american psychological association. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.88 dhr proceedings ǀ http://dhrproceedings.org 44 2023, vol. 2 no. s2 40-44 https://www.apa.org/monitor/2019/05/cecorner-isolation. published may 2019. 15. mushtaq r, shoib s, shah t, mushtaq s. relationship between loneliness, psychiatric disorders and physical health ? a review on the psychological aspects of loneliness. journal of clinical and diagnostic research. 2014;8(9). doi:https://doi.org/10.7860/jcdr/2014/10077. 4828 16. weissbourd r, batanova m, lovison v, torres e. loneliness in america: how the pandemic has deepened an epidemic of loneliness and what we can do about it. making caring common. published february 2021. https://mcc.gse.harvard.edu/reports/lonelines s-in-america 17. the university of texas at austin. coronavirus “infodemic”: fear causes misinformation spread, more rigid thinking. ut news. published january 13, 2021. https://news.utexas.edu/2021/01/13/coronavi rus-infodemic-fear-causes-misinformationspread-more-rigid-thinking/ 18. demirbas n, kutlu r. effects of covid-19 fear on society’s quality of life. international journal of mental health and addiction. published online september 15, 2021. doi:https://doi.org/10.1007/s11469021-00550-x 19. dobson et, croarkin pe, schroeder hk, et al. bridging anxiety and depression: a network approach in anxious adolescents. journal of affective disorders. 2021;280:305-314. doi:https://doi.org/10.1016/j.jad.2020.11.027 20. bbc. the surge from one covid death to one million. bbc news. https://www.bbc.com/news/world54337098. published september 29, 2020. 21. cdc. covid data tracker. centers for disease control and prevention. published march 28, 2020. accessed june 29, 2023. https://covid.cdc.gov/covid-datatracker/#maps_deaths-total 22. ettman ck, abdalla sm, cohen gh, sampson l, vivier pm, galea s. prevalence of depression symptoms in us adults before and during the covid-19 pandemic. jama network open. 2020;3(9):e2019686. doi:https://doi.org/10.1001/jamanetworkope n.2020.19686 23. salk rh, hyde js, abramson ly. gender differences in depression in representative national samples: meta-analyses of diagnoses and symptoms. psychological bulletin. 2017;143(8):783-822. doi:https://doi.org/10.1037/bul0000102 24. da silva lopes l, silva ro, de sousa lima g, de araújo costa ac, barros df, silvanéto rp. is there a common pathophysiological mechanism between covid-19 and depression? acta neurologica belgica. 2021;121(5):11171122. doi:https://doi.org/10.1007/s13760021-01748-5 25. roy d, ghosh r, dubey s, dubey mj, benito-león j, kanti ray b. neurological and neuropsychiatric impacts of covid-19 pandemic. canadian journal of neurological sciences / journal canadien des sciences neurologiques. published online august 5, 2020:1-16. doi:https://doi.org/10.1017/cjn.2020.173 26. steen od, ori aps, wardenaar kj, van loo hm. loneliness associates strongly with anxiety and depression during the covid pandemic, especially in men and younger adults. scientific reports. 2022;12(1). doi:https://doi.org/10.1038/s41598-02213049-9 27. gottert a, shattuck d, pulerwitz j, et al. meeting men’s mental health needs during covid-19 and beyond: a global health imperative. bmj global health. 2022;7(4):e008297. doi:https://doi.org/10.1136/bmjgh-2021008297 28. information nc for b, pike usnl of m 8600 r, md b, usa 20894. treatments for depression. institute for quality and efficiency in health care (iqwig); 2020. https://www.ncbi.nlm.nih.gov/books/nbk2 79282/ 29. cuijpers p, quero s, dowrick c, arroll b. psychological treatment of depression in primary care: recent developments. current psychiatry reports. 2019;21(12). doi:https://doi.org/10.1007/s11920-0191117-x 30. sarris j, o’neil a, coulson ce, schweitzer i, berk m. lifestyle medicine for depression. bmc psychiatry. 2014;14(1). doi:https://doi.org/10.1186/1471-244x-14107 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 32 2024, vol. 4 no. s2 pg. 32-41 manuscript splenda and health disparities: examining its effects on adults with type 2 diabetes in the texas-mexico border marisol acosta1, mariajose garza1,2, ana gutierrez1,2, ozzie herrera1,3, luz lieu1,3, deborah orieukwu1,3, jeremias rivas1,3 1 dhr health high school and community outreach 2 south texas isd medical professions 3 south texas isd health professions received: july 3, 2024 accepted for publication: january 24, 2025 introduction this literature review investigates the complex relationship between sucralose (splenda), a widely used artificial sweetener, and health disparities among adults with type 2 diabetes (t2d) in the texas-mexico border region. the review explores the interplay of factors contributing to the disproportionate burden of t2d and its complications in this population while examining splenda's potential role in exacerbating or mitigating these health challenges. sucralose, a chlorinated sucrose derivative, is approximately 600 times sweeter than sucrose and is largely excreted unchanged in urine. this characteristic has led to its promotion as a calorie-free alternative to sugar. however, the long-term health effects of sucralose, especially in vulnerable populations like those with t2d, remain a subject of ongoing debate. this review will synthesize existing research on splenda's effects on metabolic health, critically evaluate studies examining health disparities in the border region, and investigate the potential interaction between splenda consumption and the various factors contributing to those disparities. health disparities in the texas-mexico border region the texas-mexico border region is characterized by significant health disparities, particularly among latino populations.1-3 these disparities manifest as higher rates of chronic diseases like t2d, limited healthcare access, lower socioeconomic status, and cultural and linguistic barriers to healthcare navigation.4-6 the binational nature of the region further complicates healthcare access, with many residents utilizing healthcare systems in both the united states and mexico.2 this complex interplay of socioeconomic, cultural, and geographical factors creates a special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 33 2024, vol. 4 no. s2 pg. 32-41 challenging context for examining the health effects of dietary choices, including artificial sweetener consumption.7 poverty is a pervasive issue, with a substantial portion of the population below the federal poverty level.3.5-6 this impacts access to nutritious food, safe housing, and reliable transportation.1,5 the region also faces challenges related to access to clean water and sanitation.5 the significant presence of undocumented immigrants creates additional barriers to healthcare access due to fear of deportation and lack of legal protection.2,6 limited culturally competent healthcare providers and language barriers further complicate the issue.1,7 cultural norms and beliefs influence health behaviors and healthcare-seeking.7,8 the cumulative effect of these social determinants creates a cycle of poor health outcomes.3,9 the texas-mexico border region exhibits alarmingly high rates of diabetes and related chronic diseases.4,5,10 t2d is significantly prevalent among latinos in this area, often linked to poor dietary habits, limited physical activity, and genetic predispositions.4,5 this high prevalence contributes to increased rates of cardiovascular disease, kidney disease, and other diabetesrelated complications.4,11 obesity, a major risk factor for several cancers and t2d, is another significant health concern.5,12 the high rates of these chronic diseases place a substantial burden on individuals, families, and the healthcare system.4,13 the high rate of uninsured individuals further exacerbates these issues, limiting access to preventative care and timely treatment.2-3,6 several factors hinder access to quality healthcare and nutritional education. financial constraints are a major barrier, with many individuals lacking health insurance or facing high out-of-pocket costs.2-3,5 limited access to transportation makes it difficult to reach healthcare facilities and participate in educational programs.1,4 language barriers also present a significant challenge, as many individuals may not be fluent in english.4,7 cultural barriers, including mistrust of the healthcare system and differing cultural beliefs about health and illness, further complicate access to care.7-8 the lack of culturally tailored health education programs further limits the effectiveness of preventative measures.12 the fragmented nature of the healthcare system, with limited access to specialists and integrated care, makes it challenging to manage chronic conditions effectively.9,10 the lack of adequate resources, both financial and human, within the healthcare system often limits the capacity to provide comprehensive care and effective health education programs.6,10 this is further compounded by the increasing demand for services in a region already experiencing significant shortages of healthcare professionals, particularly specialists.10 impact of artificial sweeteners on health artificial sweeteners have become increasingly prevalent as low-calorie alternatives to sugar. while their use is driven by weight management and reduced caloric intake, their long-term health implications remain a subject of debate. this section reviews the literature on the effects of special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 34 2024, vol. 4 no. s2 pg. 32-41 artificial sweeteners, focusing on their impact on metabolic health, glycemic control, and potential risks associated with long-term consumption. numerous studies have investigated the effects of artificial sweeteners on various aspects of metabolic health. these studies have employed diverse methodologies, including randomized controlled trials (rcts) and observational studies, leading to a complex and sometimes contradictory body of evidence.14-15 some research suggests a potential link between artificial sweetener consumption and adverse metabolic outcomes, such as an increased risk of stroke, coronary heart disease, and mortality.14 however, observational studies cannot definitively establish causality. other studies have found no significant association between artificial sweetener use and negative metabolic effects.15 the discrepancies may be due to differences in study design, participant populations, types and amounts of artificial sweeteners consumed, and the duration of consumption. sucralose, often marketed as a suitable alternative for individuals with diabetes due to its negligible impact on blood glucose levels, is a widely used artificial sweetener. while acute studies show minimal effect on immediate blood glucose, the long-term effects on glycemic control remain less clear. some research suggests that regular consumption may affect gut microbiota composition and function, potentially altering metabolic processes and influencing insulin sensitivity.16 this could indirectly affect glycemic control, although the mechanisms and extent of this influence need further investigation. some evidence suggests that long-term consumption could contribute to insulin resistance, potentially impairing glycemic control.14 however, other studies have not found a clear link between artificial sweetener use and changes in insulin sensitivity or hba1c levels. concerns remain regarding potential long-term health risks associated with artificial sweeteners. these include potential adverse cardiovascular events and disruptions to the gut microbiota, leading to metabolic disturbances.14,16 some research suggests a potential link between artificial sweetener consumption and certain cancers, although more research is needed to establish a definitive causal relationship. another critical area of concern is the potential impact on weight management. while artificial sweeteners are often used to aid weight loss, some studies have reported a paradoxical association between artificial sweetener consumption and weight gain.14 this may be due to several mechanisms, including altered gut microbiota, increased appetite, and changes in energy balance. the impact of artificial sweetener consumption on kidney function and the risk of chronic kidney disease is currently unclear. the majority of research on artificial sweeteners focuses on their direct effects, often overlooking the complex interplay between dietary habits, lifestyle factors, and overall health. future research should prioritize studies that consider these interactions to provide a more comprehensive understanding of the long-term health implications of artificial sweeteners. special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 35 2024, vol. 4 no. s2 pg. 32-41 cultural considerations the cultural nuances surrounding sweetener consumption, particularly splenda, and their implications for health behaviors among adults with t2d in the texas-mexico border region. understanding these cultural factors is crucial for designing effective and culturally sensitive interventions to improve diabetes management. we will explore cultural attitudes towards sweeteners and dietary habits within the latino population, the influence of acculturation on dietary choices and health behaviors, and strategies for developing health education interventions that resonate within the specific cultural contexts of this border region. the latino population encompasses a vast array of cultural groups, each with unique traditions and dietary practices.8 traditional latino diets often incorporate naturally sweet foods like fruits and honey, but the increasing availability and marketing of processed foods and sugar-sweetened beverages have significantly altered dietary habits.8 this shift is particularly pronounced in urban areas and among more acculturated populations.8 the preference for specific sweeteners, including the acceptance or rejection of artificial sweeteners like splenda, is likely influenced by various factors, including taste preferences, perceived health benefits, and cultural beliefs about food and health.8 studies examining the specific perceptions and attitudes toward splenda amongst different latino subgroups within the border region are limited, highlighting a critical gap in the current research.8 acculturation significantly shapes dietary choices and health behaviors among latinos in the u.s.-mexico border region.8 less acculturated individuals may maintain traditional diets higher in fruits and vegetables, while more acculturated individuals may adopt diets more similar to those of the mainstream american population, often characterized by higher consumption of processed foods, sugar-sweetened beverages, and artificial sweeteners.8 this shift in dietary habits can contribute to an increased risk of t2d and related complications.8 the impact of acculturation on the use of artificial sweeteners like splenda requires further investigation.8 acculturation can also affect other health behaviors, including access to and utilization of healthcare services.2 language barriers, cultural beliefs about healthcare, and immigration status can all influence the extent to which individuals seek medical care and adhere to treatment plans.2,7 developing effective health education interventions requires careful consideration of cultural contexts. 12 interventions must be culturally sensitive and tailored to address the specific needs and beliefs of the target population.12 this includes using appropriate language, employing culturally relevant communication strategies, and incorporating culturally sensitive educational materials.12 the design of interventions should reflect an understanding of the cultural attitudes towards sweeteners and dietary habits within the specific latino subgroups of the border region.12 the role of family and community in health decision-making should also be considered.7 interventions should incorporate the family and community as partners in promoting healthy behaviors.7 addressing potential health literacy challenges is also crucial.6 health special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 36 2024, vol. 4 no. s2 pg. 32-41 education materials should be clear, concise, and easy to understand.6 the broader socioeconomic context must be considered.5 interventions should address these broader social determinants of health in addition to focusing on individual behaviors.5 methodological approaches for assessing effects this section examines the methodological approaches used in research assessing the effects of sucralose (splenda) on health outcomes, particularly its impact on adults with t2d in the texasmexico border region. a critical evaluation of these methods is crucial for understanding the strengths and limitations of existing evidence and identifying areas requiring further investigation. the review will address the types of research designs used, the importance of longitudinal studies for capturing long-term effects, and the value of mixed-methods approaches for incorporating qualitative data on patient experiences. studies investigating the effects of splenda on health have utilized a range of methodologies, including randomized controlled trials (rcts) and observational designs, such as cohort studies and case-control studies.14-15,17-18 rcts are considered the gold standard for establishing causality, but they often have limitations in terms of generalizability, particularly when studying specific populations like those in the texas-mexico border region.8 furthermore, the duration of many rcts is relatively short, limiting their ability to assess long-term effects.17 observational studies are useful for investigating long-term effects and exploring multiple risk factors, but they cannot definitively establish causality due to the presence of potential confounding variables.14 longitudinal studies, which track participants over time, are crucial for understanding the cumulative effects of splenda consumption and the potential development of chronic diseases.15 longitudinal studies can help elucidate how splenda consumption interacts with other factors, such as access to healthcare, diet, and lifestyle, to influence health outcomes in this vulnerable population.8 mixed-methods approaches, which integrate quantitative and qualitative methods, can provide a more comprehensive understanding by incorporating patients' lived experiences and perspectives.19 qualitative data, such as in-depth interviews or focus groups, can provide rich insights into how splenda use affects individuals' daily lives, their perceptions of its effects, and their decision-making processes regarding its consumption.7 in the context of the texas-mexico border region, a mixed-methods approach is particularly valuable for addressing cultural factors and health disparities.8 several methodological gaps remain. many studies lack sufficient sample sizes, limiting the statistical power and generalizability of their findings.19 furthermore, the studies often fail to adequately account for confounding variables, making it difficult to isolate the effects of splenda. future research should prioritize larger, well-designed longitudinal studies that incorporate mixed-methods approaches to address these limitations.8 these studies should specifically address the unique context of the texas-mexico border region, considering the socioeconomic, cultural, and healthcare access factors that influence diabetes management and special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 37 2024, vol. 4 no. s2 pg. 32-41 splenda use.8 studies should focus on developing and validating culturally appropriate assessment tools and questionnaires to ensure accurate data collection in this diverse population.19 conclusion this literature review examined the effects of splenda on the health of adults with type 2 diabetes (t2d) in the texas-mexico border region. the lack of direct research on splenda in this specific context highlights a critical gap in the current literature, underscoring the need for future investigations. the reviewed studies reveal a complex interplay of factors influencing diabetes management and outcomes in the texas-mexico border region. high rates of t2d among latinos in this area are well-documented, and these disparities are linked to several factors, including socioeconomic status, access to healthcare, language barriers, and a lack of social and environmental support for disease management. the studies highlight the significant challenges faced by this population, including limited health insurance coverage, insufficient provider capacity, and barriers related to transportation, cost, and fear of deportation. these challenges are exacerbated by the unique binational environment of the region, where access to healthcare in mexico may be a factor for some individuals. additionally, the influence of environmental factors, such as proximity to industrial sites, may further contribute to health disparities. the existing research on artificial sweeteners presents both potential benefits and risks. some studies suggest that artificial sweeteners may aid in weight management and not directly impact blood glucose levels, which could be beneficial for managing t2d. however, other research raises concerns about potential negative impacts on gut microbiota, insulin sensitivity, and even weight gain. the long-term effects of artificial sweeteners remain unclear, and conflicting findings highlight the need for more research. the absence of research directly investigating splenda's impact on the metabolic health of adults with t2d in this specific border region leaves a significant gap in our understanding. this gap is particularly concerning given the already existing health disparities within this vulnerable population. several crucial areas require further investigation. first, a dedicated study is needed to specifically assess the effects of splenda consumption on adults with t2d in this region. this study should consider the unique socioeconomic and environmental factors affecting this population. the study design should account for potential confounding variables, such as diet, lifestyle, access to healthcare, and other health conditions, to isolate the effects of splenda. second, research should explore the potential interaction between splenda consumption and the gut microbiome within this population. the gut microbiome plays a critical role in metabolic health, and alterations to its composition could significantly impact diabetes management. this research should employ advanced techniques to analyze the gut microbiome's composition and function in response to splenda consumption. third, research should investigate the long-term special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 38 2024, vol. 4 no. s2 pg. 32-41 effects of splenda consumption on cardiovascular health and other diabetes-related complications in this population. the existing literature on artificial sweeteners shows conflicting results regarding their long-term effects, and this needs clarification specifically in the context of the texas-mexico border region. longitudinal studies are necessary to track the health outcomes of individuals consuming splenda over an extended period. fourth, qualitative research methods could provide valuable insights into the perspectives and experiences of individuals with t2d in this region regarding their dietary choices and perceptions of artificial sweeteners. understanding the cultural context and social determinants of health is crucial for designing effective interventions. finally, comparative studies are needed to assess the relative effectiveness of splenda versus other sweeteners or dietary approaches in managing t2d within this population. this will help determine if splenda offers any advantages or disadvantages compared to other options. given the existing health disparities and the lack of specific research on splenda's effects in the texas-mexico border region, healthcare practitioners should exercise caution when recommending artificial sweeteners to their patients with t2d. while some individuals might find artificial sweeteners helpful for managing weight or improving glycemic control in the short term, the long-term consequences remain uncertain. healthcare providers should prioritize a holistic approach to diabetes management, emphasizing lifestyle modifications such as dietary changes, physical activity, and stress management. it's crucial to consider individual patient needs and preferences while providing personalized dietary guidance. patients should be educated about the potential benefits and risks of various dietary options, including artificial sweeteners. healthcare providers should also address the broader social determinants of health that influence dietary choices and diabetes management, such as access to healthy foods, socioeconomic factors, and cultural beliefs. furthermore, they should actively work to improve access to comprehensive diabetes care, including culturally sensitive education and support programs, for this vulnerable population. given the high prevalence of diabetes and the existing health disparities in the texas-mexico border region, a multi-faceted approach is essential to effectively manage and prevent this chronic disease. the integration of culturally tailored interventions, alongside efforts to address social determinants of health, is vital to improving diabetes outcomes and promoting health equity in this region. until more research is available specifically on splenda's impact within this population, a cautious and comprehensive approach to diabetes management is paramount. acknowledgements: nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 39 2024, vol. 4 no. s2 pg. 32-41 funding: funded by dhr health high school and community outreach; dhr health; south texas independent school district. references 1. martinez-gómez v, walker gc, davis m, aviles jl, flynn a, cho s. prevention care management unit: telephone care management to improve appointment compliance along the south-texas mexico border. international journal of nursing and health care research. published online january 1, 2019. 2. bastida e, brown hs, pagán ja. persistent disparities in the use of health care along the us–mexico border: an ecological perspective. american journal of public health. 2008;98(11):1987-1995. doi:https://doi.org/10.2105/ajph.2007.114447 3. castañeda h. is coverage enough? persistent health disparities in marginalised latino border communities. journal of ethnic & migration studies. 2017;43(12):2003-2019. doi:https://doi.org/10.1080/1369183x.2017.1323448 4. casey rp, rouff ma, jauregui-covarrubias l. diabetes among latinos in the southwestern united states: border health and binational cooperation. doaj (doaj: directory of open access journals). 2014;36(6):391-395. 5. mangadu t, kelly m, orezzoli mce, gallegos r, matharasi p. best practices for community gardening in a us–mexico border community. health promotion international. 2016;32(6):daw025. doi:https://doi.org/10.1093/heapro/daw025 6. boom k, lopez m, daheri m, et al. perspectives on cervical cancer screening and prevention: challenges faced by providers and patients along the texas–mexico border. perspectives in public health. 2018;139(4):199-205. doi:https://doi.org/10.1177/1757913918793443 7. escobar r, gonzalez j, longoria d, rodriguez n. challenges faced by mexican americans when accessing mental health care service utilization along the south texas – mexico border. journal of mental health and social behaviour. 2021;3(1). doi:https://doi.org/10.33790/jmhsb1100128 8. ghaddar s, brown cj, pagán ja, díaz v. acculturation and healthy lifestyle habits among hispanics in united states-mexico border communities. revista panamericana de salud pública. 2010;28(3). doi:https://doi.org/10.1590/s1020-49892010000900009 9. burkhalter n, walker ss, davis m, flynn a. integrating primary, behavioral and spiritual health care to improve patient outcomes. journal of behavioral health and psychology. 2021;10(4). doi:https://doi.org/10.33425/2832-4579/21033 10. valentine sampson alia, ed wong alvarado, diaz em, reinhart h. disparities in available surgeons and specialty physicians providing endocrine-related health care coverage to populations in south texas and the rio grande valley. journal of the https://doi.org/10.2105/ajph.2007.114447 https://doi.org/10.1080/1369183x.2017.1323448 https://doi.org/10.1093/heapro/daw025 https://doi.org/10.1177/1757913918793443 https://doi.org/10.33790/jmhsb1100128 https://doi.org/10.1590/s1020-49892010000900009 https://doi.org/10.33425/2832-4579/21033 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 40 2024, vol. 4 no. s2 pg. 32-41 endocrine society. 2023;7(supplement_1). doi:https://doi.org/10.1210/jendso/bvad114.1865 11. white g, dentistry p. citation: white ge. see cavities, think systemic disease. j oral bio. 2016;3(2). 12. miller m, valenzuela r, salinas jj. change in nutrition behavior after participating in an obesity-related cancer education program in el paso, texas. cancer control. 2024;31. doi:https://doi.org/10.1177/10732748241261567 diaz fc, osuna-salazar en, robledo c, machiorlatti m, sarhill n, kwang h. trends and variations in female breast cancer along the texas-mexico border trends and variations in breast cancer along the texas-mexico border. cancer research. 2020;80(4_supplement):p6-1104-p611-04. doi:https://doi.org/10.1158/15387445.sabcs19-p6-11-04 13. m m, vellapandian c. exploring the long-term effect of artificial sweeteners on metabolic health. cureus. published online september 23, 2024. doi:https://doi.org/10.7759/cureus.70043 14. guru sk, li y, savinova ov, zhang y. long-term consumption of artificial sweeteners does not affect cardiovascular health and survival in rats. peerj. 2022;10:e13071. doi:https://doi.org/10.7717/peerj.13071 15. matcha angelin, kumar j, leela kakithakara vajravelu, abhishek satheesan, venkata chaithanya, murugesan r. artificial sweeteners and their implications in diabetes: a review. frontiers in nutrition. 2024;11. doi:https://doi.org/10.3389/fnut.2024.1411560 16. li pwc, yu dsf, chong sok, lin rsy. a systematic review on the effects of nonpharmacological sleep interventions on cardiometabolic risk or disease outcomes. journal of cardiovascular nursing. 2020;35(2):184-198. doi:https://doi.org/10.1097/jcn.0000000000000662 17. link to external site this link will open in a new tab. protocol for a randomized controlled trial comparing a very low-carbohydrate diet or moderate-carbohydrate plate-method diet for type 2 diabetes: the legend (lifestyle education about nutrition for diabetes) trial. proquest. published online december 1, 2023:463. doi:https://doi.org/10.1186/s13063-023-07512-9 18. avila a, cordero j, osinachi ibilah, frietze g, moya em. hispanic survivors and caregivers of human papillomavirus–associated cancers: lived experiences in a u.s.– mexico border community. health education & behavior. 2022;50(5):595-603. doi:https://doi.org/10.1177/10901981221139179 19. staudt k, dane’el m, márquez-velarde g. in the shadow of a steel recycling plant in these neoliberal times: health disparities among hispanics in a bordercolonia. local environment. 2015;21(5):636-652. doi:https://doi.org/10.1080/13549839.2015.1016902 https://doi.org/10.1210/jendso/bvad114.1865 https://doi.org/10.1177/10732748241261567 https://doi.org/10.1158/1538-7445.sabcs19-p6-11-04 https://doi.org/10.1158/1538-7445.sabcs19-p6-11-04 https://doi.org/10.7759/cureus.70043 https://doi.org/10.7717/peerj.13071 https://doi.org/10.3389/fnut.2024.1411560 https://doi.org/10.1097/jcn.0000000000000662 https://doi.org/10.1186/s13063-023-07512-9 https://doi.org/10.1177/10901981221139179 https://doi.org/10.1080/13549839.2015.1016902 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.5 dhr proceedings ǀ http://dhrproceedings.org 41 2024, vol. 4 no. s2 pg. 32-41 20. putra kwr, toonsiri c. factors influencing health behavior among type 2 diabetes mellitus patients: an integrative review. belitung nursing journal. 2017;3(1):32-40. doi:https://doi.org/10.33546/bnj.46 21. gunter ke, peek me, tanumihardjo jp, et al. population health innovations and payment to address social needs among patients and communities with diabetes. the milbank quarterly. 2021;99(4):928-973. doi:https://doi.org/10.1111/1468-0009.12522 22. hu l, lin nf, shi y, et al. the integrating cultural aspects into diabetes education study to prevent diabetes in chinese immigrants: protocol for a randomized controlled trial (preprint). jmir research protocols. 2024;13:e65455-e65455. doi:https://doi.org/10.2196/65455 https://doi.org/10.33546/bnj.46 https://doi.org/10.1111/1468-0009.12522 https://doi.org/10.2196/65455 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is.2 dhr proceedings ǀ http://dhrproceedings.org 8 2024, vol. 4 no. s2 pg. 8-14 manuscript monosodium glutamate exposure in fast food and its contribution to obesity risk among college-aged hispanics on the texasmexico border marisol acosta1, delgado barbara1,3, garcia jeyra1,3, gomez liani1,2, martinez david1,3, mendoza marcelo1,3, susa reeanne1.3, torres marian1,2, winkler sarah1,2 1dhr health high school and community outreach 2 stisd medical professions 3stisd health professions received: july 3, 2024 accepted for publication: january 24, 2025 introduction this literature review examines the potential link between monosodium glutamate (msg) exposure through fast food consumption and obesity risk among college-aged hispanics residing on the texas-mexico border. the high prevalence of obesity and related comorbidities among us hispanics/latinos necessitates investigation into various contributing factors, including dietary habits and the consumption of processed foods often containing msg.1 while research directly linking msg to obesity in humans remains inconclusive, several studies suggest potential mechanisms and indirect associations warranting further exploration, especially within specific at-risk populations.2 this review will synthesize existing research on msg's effects, dietary patterns of border hispanics, and the role of the food environment in shaping health outcomes. monosodium glutamate (msg): a review of potential health implications msg, a flavor enhancer widely used in processed foods, including many fast-food items, is the sodium salt of glutamic acid.2-3 while generally recognized as safe (gras) by regulatory bodies, concerns persist regarding its potential long-term health effects.4-5 animal studies have demonstrated msg's neurotoxicity, particularly when administered neonatally.2-3,6-7 these studies report various adverse effects including weight gain, obesity, and changes in behavior and memory.2-3 however, the extrapolation of these findings to human populations, especially with regards to oral consumption at levels typically found in food, remains a significant challenge.8 furthermore, the mechanisms through which msg might contribute to obesity are not fully understood.2,9 some research suggests that msg may influence leptin resistance, special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is.2 dhr proceedings ǀ http://dhrproceedings.org 9 2024, vol. 4 no. s2 pg. 8-14 inhibit growth hormone, and increase central adiposity.2 other studies point to msg's potential role in disrupting the hypothalamic-pituitary-gonadal (hpg) axis, affecting reproductive function and potentially influencing metabolic processes.9 a recent study even suggests a link between msg exposure and cardiovascular disease risk, highlighting the need for further investigation into its multifaceted effects on health.5 the inconsistencies between animal and human studies concerning the dosage and effects of msg necessitate caution in interpreting the results.4 several studies have focused on the development of methods for measuring msg in various matrices, including food products and biological samples.10-11 this development is crucial for accurate assessment of msg exposure and its potential health consequences. the development of accurate and reliable methods for measuring msg in different food matrices is crucial for understanding actual exposure levels and their potential implications.10-11 further research is needed to clarify the specific mechanisms by which msg might influence metabolic processes and contribute to obesity. dietary habits and obesity among college-aged hispanics on the texas-mexico border the texas-mexico border region presents a unique context for studying obesity and dietary habits. this area is characterized by a high prevalence of obesity among hispanic populations, influenced by a confluence of factors including acculturation, socioeconomic status, and access to healthy food options.12-15 studies have shown that acculturation to american culture is often associated with shifts in dietary patterns, increasing the consumption of processed foods, sugary drinks, and fast food.14,16 the transition to a "westernized" diet, often high in saturated fats, refined carbohydrates, and sodium, is a significant contributor to obesity risk.13-17 moreover, limited access to fresh produce and healthy food options, particularly in low-income communities, creates a "food desert" effect, exacerbating the issue.12 the complex interplay between acculturation, socioeconomic factors, and the food environment makes it challenging to isolate the specific contribution of msg to obesity risk within this population. a significant portion of the diet among this population consists of prepared foods, some of which are processed at high temperatures, potentially altering the msg content and bioavailability.18 the high consumption of prepared foods across both rural and urban regions of this area necessitates further investigation into the role of msg and other food additives in shaping dietary patterns and obesity risk.18 furthermore, the role of cultural norms and food preferences in shaping dietary choices should be considered in future interventions aiming to improve dietary quality among hispanic groups.14 msg exposure from fast food and obesity risk: connecting the dots while no studies directly address the specific contribution of msg exposure from fast food to obesity risk in college-aged hispanics on the texas-mexico border, several lines of evidence suggest potential indirect associations. the high consumption of fast food, often rich in msg and other unhealthy ingredients, is a well-established risk factor for obesity.12,15,19 the potential mechanisms by which msg might contribute to obesity, such as its influence on leptin resistance and growth hormone, as discussed earlier, could be particularly relevant in a population already at high risk due to other dietary and lifestyle factors.2 moreover, the prevalence of emotional eating, a behavior linked to increased fast food consumption, could further exacerbate the impact of msg exposure.19 the high prevalence of overweight and obesity among this population highlights the need for further research in this area.1,20-21 the high prevalence of obesity among special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is.2 dhr proceedings ǀ http://dhrproceedings.org 10 2024, vol. 4 no. s2 pg. 8-14 college-aged females in saudi arabia, as well as the significant correlation between perceived body size and bmi, suggests a similar trend that might be applicable to college-aged hispanic women on the texas-mexico border.21 the impact of psychosocial factors should be considered in future research, as these factors may influence body image perception and dietary choices.21 additionally, the effect of racial/ethnic discrimination as a psychosocial stressor on bmi and other cvd risk factors among college students of color suggests that these factors should also be taken into account when studying obesity in this specific population.22 research gaps and future directions several critical research gaps need to be addressed to fully understand the contribution of msg exposure from fast food to obesity risk among college-aged hispanics on the texas-mexico border. firstly, longitudinal studies are needed to track msg intake and its association with weight change over time within this specific population.13 cross-sectional studies, while providing valuable insights, cannot establish causality.23 secondly, more research is required to assess msg exposure levels from fast food specifically consumed by this demographic. this would require detailed dietary assessments and analysis of msg content in commonly consumed fast-food items within the region.18 thirdly, studies should investigate the interaction between msg exposure and other dietary and lifestyle factors that contribute to obesity risk in this population.12,14-15 this includes examining the impact of acculturation, socioeconomic status, access to healthy food, and physical activity levels.16-17 fourthly, research should investigate the potential mediating role of emotional eating and other psychological factors in the relationship between msg exposure and obesity.19 finally, culturally relevant interventions are needed to address dietary habits and promote healthier eating behaviors within this community.14,24 furthermore, the role of food marketing and its impact on the consumption of msg-containing fast food, particularly among youth, needs further investigation.24 conclusion while the direct link between msg exposure from fast food and obesity risk in college-aged hispanics on the texas-mexico border is not definitively established, several indirect associations exist. the high prevalence of obesity in this population, coupled with the widespread consumption of fast food and the potential mechanisms through which msg might contribute to obesity, warrants further investigation. future research should address critical research gaps through longitudinal studies, detailed dietary assessments, and consideration of the interaction between msg exposure and other relevant factors. such research is critical for developing effective interventions to address the significant public health challenge of obesity in this vulnerable population. the development of culturally sensitive interventions that address the complex interplay between food environment, dietary habits, and psychosocial factors is essential for promoting healthy eating behaviors and reducing obesity risk within this population. furthermore, the potential impact of msg on the reproductive system and the long-term health consequences of msg consumption warrant further investigation. the potential for msginduced genotoxic effects also needs further study in human populations. the role of genetic factors in taste perception and food preferences should also be taken into account, as these factors could influence the consumption of msg-containing foods. finally, the influence of food insecurity on dietary choices and obesity risk in this population should be considered. the high prevalence of food insecurity among college students suggests that this factor could further special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is.2 dhr proceedings ǀ http://dhrproceedings.org 11 2024, vol. 4 no. s2 pg. 8-14 exacerbate the risk of obesity. addressing the multifaceted issues of food insecurity, dietary habits, and the impact of msg requires a comprehensive approach that combines scientific research with culturally sensitive interventions. acknowledgements nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. funding: funded by dhr health high school and community outreach; dhr health; south texas independent school district. references 1. qi q, strizich g, hanna db, et al. comparing measures of overall and central obesity in relation to cardiometabolic risk factors among us hispanic/latino adults. obesity. 2015;23(9):1920-1928. doi:https://doi.org/10.1002/oby.21176 2. pepino my, finkbeiner s, beauchamp gk, mennella ja. obese women have lower monosodium glutamate taste sensitivity and prefer higher concentrations than do normal-weight women. obesity. 2010;18(5):959-965. doi:https://doi.org/10.1038/oby.2009.493 3. zanfirescu a, ungurianu a, tsatsakis am, et al. a review of the alleged health hazards of monosodium glutamate. comprehensive reviews in food science and food safety. 2019;18(4):1111-1134. doi:https://doi.org/10.1111/1541-4337.12448 4. rutska a, getsko n, krynytska i. toxic impact of monosodium glutamate on a living organism. medical and clinical chemistry. 2017;1(1). doi:https://doi.org/10.11603/mcch.2410-681x.2017.v0.i1.7685 5. hasenböhler a, javaux g, payen m, et al. food additive monosodium glutamate and risk of cardiovascular diseases nutrinet-santé cohort. european journal of public health. 2024;34(supplement_3). doi:https://doi.org/10.1093/eurpub/ckae144.234 6. mateshuk-vatseba lr, holovatskyi as, harapko tv, foros ai, v. lytvak y. changes in the structural organization of lymph nodes during short-term exposure to monosodium glutamate. reports of morphology. 2022;28(4):34-40. doi:https://doi.org/10.31393/morphology-journal-2022-28(4)-05 7. bhattacharya t, ghosh sk. effect of neonatal exposure of monosodium glutamate in kidney of albino mice: a histological study. nepal medical college journal. 2019;21(2):134-141. doi:https://doi.org/10.3126/nmcj.v21i2.25113 8. shimada a, cairns b, svensson p. authors’ reply to the comment by fernstrom. european journal of pain. 2017;21(4):763-764. doi:https://doi.org/10.1002/ejp.1028 https://doi.org/10.1002/oby.21176 https://doi.org/10.1038/oby.2009.493 https://doi.org/10.1111/1541-4337.12448 https://doi.org/10.11603/mcch.2410-681x.2017.v0.i1.7685 https://doi.org/10.1093/eurpub/ckae144.234 https://doi.org/10.31393/morphology-journal-2022-28(4)-05 https://doi.org/10.3126/nmcj.v21i2.25113 https://doi.org/10.1002/ejp.1028 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is.2 dhr proceedings ǀ http://dhrproceedings.org 12 2024, vol. 4 no. s2 pg. 8-14 9. haddad m, esmail r, khazali h. reporting the effects of exposure to monosodium glutamate on the regulatory peptides of the hypothalamic-pituitary-gonadal axis. international journal of fertility & sterility. 2021;15(4):246-251. doi:https://doi.org/10.22074/ijfs.2021.522615.1072 10. a.c. knyazeva, n.l. vostrikova, a.v. kulikovsky, d.a. utyanov, a.a. kurzova. methodology for measuring the mass fraction of monosodium glutamate in meat matrices. bio web of conferences. 2024;103:00088-00088. doi:https://doi.org/10.1051/bioconf/202410300088 11. knyazeva as, vostrikova nl, kulikovskii av, utyanov da. method and metrological characteristics of measuring the mass fraction of monosodium glutamate in biological matrices. food systems. 2022;5(3):223-231. doi:https://doi.org/10.21323/2618-97712022-5-3-223-231 12. jae in oh, kangjae jerry lee, hipp a. food deserts exposure, density of fast-food restaurants, and park access: exploring the association of food and recreation environments with obesity and diabetes using global and local regression models. plos one. 2024;19(4):e0301121-e0301121. doi:https://doi.org/10.1371/journal.pone.0301121 13. salem v, alhusseini n, abdul razack hi, naoum a, sims ot, alqahtani sa. prevalence, risk factors, and interventions for obesity in saudi arabia: a systematic review. obesity reviews. 2022;23(7). doi:https://doi.org/10.1111/obr.13448 14. brown sa, becker ha, garcía aa, et al. acculturation, dietary behaviors, and macronutrient intake among mexican americans with prediabetes: the starr county diabetes prevention initiative. the science of diabetes self-management and care. 2023;49(1):65-76. doi:https://doi.org/10.1177/26350106221146473 15. atanasova p, kusuma d, pineda e, frost g, sassi f, miraldo m. the impact of the consumer and neighbourhood food environment on dietary intake and obesity-related outcomes: a systematic review of causal impact studies. social science & medicine. 2022;299:114879. doi:https://doi.org/10.1016/j.socscimed.2022.114879 16. kwon s, wang-schweig m, kandula nr. body composition, physical activity, and convenience food consumption among asian american youth: 2011–2018 nhanes. international journal of environmental research and public health. 2020;17(17):6187. doi:https://doi.org/10.3390/ijerph17176187 17. zhao y, araki t. diet quality and its associated factors among adults with overweight and obesity: findings from the 2015–2018 national health and nutrition examination survey. british journal of nutrition. 2023;131(1):134-142. doi:https://doi.org/10.1017/s0007114523001587 18. lioe h, dyahpakarti g, zakaria n, sudrajat h, rahayu i. exposure assessment of monosodium glutamate in prepared foods with frying, sautéing, grilling or baking process. proceedings of the 2nd seafast international seminar. published online 2019:49-56. doi:https://doi.org/10.5220/0009978100490056 https://doi.org/10.22074/ijfs.2021.522615.1072 https://doi.org/10.1051/bioconf/202410300088 https://doi.org/10.21323/2618-9771-2022-5-3-223-231 https://doi.org/10.21323/2618-9771-2022-5-3-223-231 https://doi.org/10.1371/journal.pone.0301121 https://doi.org/10.1111/obr.13448 https://doi.org/10.1177/26350106221146473 https://doi.org/10.1016/j.socscimed.2022.114879 https://doi.org/10.3390/ijerph17176187 https://doi.org/10.1017/s0007114523001587 https://doi.org/10.5220/0009978100490056 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is.2 dhr proceedings ǀ http://dhrproceedings.org 13 2024, vol. 4 no. s2 pg. 8-14 19. elran barak r, shuval k, li q, et al. emotional eating in adults: the role of sociodemographics, lifestyle behaviors, and self-regulation—findings from a u.s. national study. international journal of environmental research and public health. 2021;18(4):1744. doi:https://doi.org/10.3390/ijerph18041744 20. samer koutoubi, huffman fg. body composition assessment and coronary heart disease risk factors among college students of three ethnic groups. pubmed. 2005;97(6):784-791. 21. albeeybe j, alomer a, alahmari t, et al. body size misperception and overweight or obesity among saudi college-aged females. journal of obesity. 2018;2018:1-9. doi:https://doi.org/10.1155/2018/5246915 22. serpas dg, garcía jj, arellano-morales l. a path model of racial/ethnic discrimination and cardiovascular disease risk factors among college students of color. journal of american college health. published online november 5, 2020:1-5. doi:https://doi.org/10.1080/07448481.2020.1841772 23. coll jl, bibiloni m del m, salas r, pons a, tur ja. prevalence and related risk factors of overweight and obesity among the adult population in the balearic islands, a mediterranean region. obesity facts. 2015;8(3):220-233. doi:https://doi.org/10.1159/000435826 24. harris jl, brownell kd, bargh ja. the food marketing defense model: integrating psychological research to protect youth and inform public policy. social issues and policy review. 2009;3(1):211-271. doi:https://doi.org/10.1111/j.1751-2409.2009.01015.x 25. abbey el, brown m, karpinski c. prevalence of food insecurity in the general college population and student-athletes: a review of the literature. current nutrition reports. published online february 26, 2022. doi:https://doi.org/10.1007/s13668-022-00394-4 26. leyla a.a abu-hussein. the role of food program to overcome obesity, overweight, and underweight among autistic children. the scientific temper. 2023;14(03):895-901. doi:https://doi.org/10.58414/scientifictemper.2023.14.3.52 27. oliveira pf, sousa m, silva bm, monteiro mp, alves mg. obesity, energy balance and spermatogenesis. reproduction. 2017;153(6):r173-r185. doi:https://doi.org/10.1530/rep-17-0018 28. shehab ng, omolaoye ts, du ss, et al. phytochemical evaluation of lepidium meyenii, trigonella foenum-graecum, spirulina platensis, and tribulus arabica, and their potential effect on monosodium glutamate induced male reproductive dysfunction in adult wistar rats. antioxidants. 2024;13(8):939-939. doi:https://doi.org/10.3390/antiox13080939 29. das d, banerjee a, bhattacharjee a, mukherjee s, maji bk. dietary food additive monosodium glutamate with or without high-lipid diet induces spleen anomaly: a mechanistic approach on rat model. open life sciences. 2022;17(1):22-31. doi:https://doi.org/10.1515/biol-2022-0004 https://doi.org/10.3390/ijerph18041744 https://doi.org/10.1155/2018/5246915 https://doi.org/10.1080/07448481.2020.1841772 https://doi.org/10.1159/000435826 https://doi.org/10.1111/j.1751-2409.2009.01015.x https://doi.org/10.1007/s13668-022-00394-4 https://doi.org/10.58414/scientifictemper.2023.14.3.52 https://doi.org/10.1530/rep-17-0018 https://doi.org/10.3390/antiox13080939 https://doi.org/10.1515/biol-2022-0004 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is.2 dhr proceedings ǀ http://dhrproceedings.org 14 2024, vol. 4 no. s2 pg. 8-14 30. manal salah el-gendy, eman sobhy el-gezawy, saleh aa, et al. investigating the chemical composition of lepidium sativum seeds and their ability to safeguard against monosodium glutamate-induced hepatic dysfunction. foods. 2023;12(22):4129-4129. doi:https://doi.org/10.3390/foods12224129 31. zedan a, galal o, al-anany f. potential effects of some natural food additives against monosodium glutamate-induced genotoxicity in vicia faba. egyptian journal of genetics and cytology. 2018;46(2):371-388. doi:https://doi.org/10.21608/ejgc.2018.9210 32. chamoun e, mutch dm, allen-vercoe e, et al. a review of the associations between single nucleotide polymorphisms in taste receptors, eating behaviors, and health. critical reviews in food science and nutrition. 2017;58(2):194-207. doi:https://doi.org/10.1080/10408398.2016.1152229 https://doi.org/10.3390/foods12224129 https://doi.org/10.21608/ejgc.2018.9210 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 30 2024, vol. 4 no. s1 pg. 30-44 manuscript high fructose corn syrup’s role in obesity among hispanic adolescent females in the texas-mexico border marisol acosta1, anna elizondo1,2, allyson gutierrez1,3, joelen mendoza1,4, gia rico1,5, alexia rodriguez1,6, belinda sustaita1,7, arianna vela1,2, ximena galaviz1,4 1dhr health high school and community outreach 2 san isidro high school 3 lamar academy 4 psja early college high school 5 sharyland high school 6 rio hondo high school 7 la joya high school received: july 12, 2024 accepted for publication: january 6, 2025 published: january 7, 2025 introduction this literature review examines the complex relationship between high-fructose corn syrup (hfcs) consumption, obesity, and its disproportionate impact on hispanic adolescent females in the texas-mexico border region. the rising obesity rates in this demographic require a thorough investigation into contributing factors, focusing on hfcs, a prevalent sweetener in modern diets. this review will explore hfcs prevalence in hispanic adolescents' diets, the significance of studying this population in the texas-mexico border region, and the established link between hfcs consumption and obesity, especially within vulnerable populations. we will summarize the mechanisms linking hfcs to obesity, the influence of socioeconomic factors, and the implications for interventions and public health. background on obesity in hispanic adolescents obesity among adolescents is a significant public health concern, with hispanic youth, particularly females, experiencing disproportionately high rates, especially in regions like the texas-mexico border. understanding this disparity requires examining epidemiological data and the sociocultural context. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 31 2024, vol. 4 no. s1 pg. 30-44 prevalence of obesity data on obesity statistics for hispanic adolescent females in the texas-mexico border region are limited. however, studies show elevated obesity risk within the broader hispanic adolescent population in the us and texas. nationally, 17.1% of 2–19-year-olds are obese [1], a figure likely higher for hispanic adolescents [2]. a study in el paso county, texas (predominantly mexican-origin hispanic, 83%) found a positive association between hispanic ethnic concentration and obesity prevalence [3]. this lack of specific data on hispanic adolescent females in this border region highlights a significant research gap. socioeconomic factors socioeconomic factors significantly contribute to obesity in this population. limited healthcare access, including delayed diagnosis and treatment of obesity-related conditions, is worsened by socioeconomic inequities like lack of health insurance and insufficient health education [3]. lower median incomes are linked to higher obesity prevalence, while higher education levels demonstrate a protective effect [3]. food insecurity, common in low-income households, leads to reliance on less nutritious, energy-dense foods, often cheaper and more readily available [4]. this creates a cycle of disadvantage, where limited resources increase obesity risk and associated health problems. a study on family-based obesity prevention interventions among hispanic youth found that younger children from low socioeconomic backgrounds were well-represented [5], indicating a strong correlation between socioeconomic status and obesity risk. cultural and environmental factors cultural and environmental factors also impact dietary habits and obesity rates. the traditional hispanic diet, while historically featuring fresh produce, has changed with increased exposure to processed foods and sugar-sweetened beverages [6]. the availability and affordability of these less healthy options, combined with changing cultural norms and lifestyles, contribute to increased caloric intake and reduced physical activity [4]. high consumption of sugar-sweetened beverages, a major source of added sugars [1], is particularly concerning, as it's linked to weight gain [1], [7]. a study examining the relationship between acculturation and dietary patterns showed that sugar intake significantly exceeded recommendations across all adolescent cultural categories [6], suggesting that cultural shifts may not always lead to healthier dietary choices. physical activity and sedentary behavior physical inactivity is a significant contributing factor to obesity, particularly along the texasmexico border [8]. limited access to safe spaces for physical activity, coupled with increased screen time and sedentary behaviors [9], contribute to the problem. interventions promoting special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 32 2024, vol. 4 no. s1 pg. 30-44 physical activity have shown mixed results [8]. a family-based intervention aimed at reducing screen-based sedentary behavior showed some success in reducing sedentary behavior in overweight and obese youth but not in severely obese youth [9]. a study found that most caloric, carbohydrate, and added sugar intake in a cohort of hispanic adolescents with obesity occurred between 11:00 am and 7:00 pm [10], suggesting that interventions targeting specific eating periods may be beneficial. role of high-fructose corn syrup while the exact contribution of hfcs to obesity among hispanic adolescent females in the texas-mexico border region isn't explicitly addressed in all provided documents, the extensive research linking hfcs consumption to weight gain warrants consideration. hfcs consumption has significantly increased in the united states in recent decades [12], coinciding with a rise in obesity rates [12]. studies have shown that hfcs, particularly in beverages, may play a role in the obesity epidemic [12], [13]. however, the relationship between hfcs and obesity is complex and not fully understood [14], [13], with some studies showing mixed results or null effects [13]. the potential metabolic effects of hfcs, such as its impact on de novo lipogenesis, insulin resistance, and triglyceride levels [15], [16], are relevant to understanding obesity development. further research is needed to determine the specific role of hfcs in the context of hispanic adolescent females in the texas-mexico border region, considering the interplay with other socioeconomic, cultural, and environmental factors. mechanisms linking hfcs to obesity this section explores the biological mechanisms through which hfcs may contribute to obesity, focusing on its impact on metabolism and weight gain, particularly in hispanic adolescent females in the texas-mexico border region. the research on hfcs and obesity is extensive, but its specific impact on this demographic requires careful consideration of cultural factors and socioeconomic influences. insulin resistance and impaired glucose homeostasis one primary mechanism linking hfcs consumption to obesity is its potential to induce insulin resistance. insulin regulates blood glucose levels and glucose uptake. impaired insulin action leads to hyperglycemia and fat storage. studies show that fructose, a major component of hfcs, may be particularly implicated[13], [14]. fructose metabolism bypasses primary regulatory steps of glucose metabolism, resulting in less glucose-mediated insulin secretion and a greater likelihood of hepatic de novo lipogenesis [13]. this increased lipogenesis contributes to elevated triglyceride levels and ectopic fat deposition, further contributing to insulin resistance and metabolic dysfunction [16]. chronic elevation of blood glucose and insulin levels associated special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 33 2024, vol. 4 no. s1 pg. 30-44 with insulin resistance promotes weight gain and obesity development [13]. the impact of this mechanism may be heightened in hispanic adolescents due to genetic predispositions or other underlying health conditions [2], [15]. increased appetite and reduced satiety hfcs may influence obesity through its impact on appetite regulation. fructose has a limited effect on satiety hormones, such as leptin and ghrelin [17]. fructose does not effectively suppress ghrelin release, a hormone that stimulates appetite [17]. this lack of satiety signaling may lead to increased food intake and positive energy balance, a major driver of weight gain [17]. the high palatability of hfcs-sweetened beverages may lead to increased consumption [7]. the combination of reduced satiety and increased consumption of palatable, hfcs-containing foods and beverages can create a cycle of overeating and weight gain, particularly in adolescents [7]. cultural factors within the hispanic community may also influence the consumption of hfcssweetened products [6]. liver metabolism and non-alcoholic liver disease (nafld) excessive fructose intake can overwhelm the liver's metabolic capacity, leading to increased de novo lipogenesis and triglyceride accumulation in the liver, a hallmark of nafld [13], [16]. nafld is strongly associated with obesity and insulin resistance, creating a vicious cycle that exacerbates weight gain [18]. studies suggest that hfcs may contribute to nafld development more significantly than sucrose [18]. the prevalence of nafld among hispanic adolescents is a concern requiring further study. impact of hfcs on gut microbiota hfcs consumption can alter the composition and function of the gut microbiota [18], potentially promoting an environment that favors increased energy harvest and fat storage. these changes may be mediated through alterations in short-chain fatty acid (scfa) production, impacting energy metabolism and gut barrier function [18]. the impact of hfcs on the gut microbiota may vary depending on individual factors, including genetics and pre-existing gut microbial composition. this variation is especially relevant when considering the diverse genetic backgrounds and potential dietary habits within the hispanic population [18]. neurobiological effects and cognitive function some research suggests that hfcs consumption may impact cognitive function, indirectly influencing eating behaviors. studies in animal models have indicated that hfcs consumption can negatively affect hippocampal-dependent spatial learning and memory [19], a brain region special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 34 2024, vol. 4 no. s1 pg. 30-44 involved in learning, memory, and reward processing. these findings suggest a potential link between hfcs consumption, altered brain function, and potentially impulsive food choices, though further research is required to fully understand this complex relationship in humans, especially in the context of hispanic adolescent females [19]. limitations and future research directions while evidence linking hfcs consumption to obesity is substantial, limitations exist. many studies rely on self-reported dietary intake data, which may be inaccurate [1]. furthermore, research often focuses on the effects of hfcs in isolation without considering the complex interplay of genetic, environmental, and socioeconomic factors that influence obesity risk [20]. future research needs to employ more rigorous methodologies, including objective measures of hfcs intake and comprehensive assessments of relevant confounding variables within specific populations, such as hispanic adolescent females in the texas-mexico border region [20]. studies should also investigate the potential interactions between hfcs consumption and other lifestyle factors, such as physical activity and sleep patterns [21], to better understand the overall contribution of hfcs to obesity in this vulnerable population. influence of socioeconomic factors the high rates of obesity among hispanic adolescent females along the texas-mexico border cannot be understood without considering socioeconomic factors. these factors create environmental, behavioral, and access-related challenges significantly impacting hfcs consumption and obesity development. socioeconomic disparities and obesity rates research highlights the strong correlation between socioeconomic status (ses) and obesity prevalence, including among hispanic adolescents [2], [22], [3]. lower income levels are consistently associated with higher obesity rates [22]. families with limited resources often rely on less expensive, energy-dense foods high in added sugars, including hfcs-sweetened beverages and processed foods [23], [15]. these foods provide more calories for less cost. access to healthy, fresh produce is often limited in lower-income neighborhoods, leading to reliance on less nutritious options frequently containing hfcs [20]. the lack of access to resources that promote healthy lifestyles also plays a role. low-income families may lack access to safe places for physical activity or have transportation limitations restricting access to grocery stores offering healthier food choices [20]. financial insecurity and limited access to resources can negatively impact health behaviors. chronic stress, linked to special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 35 2024, vol. 4 no. s1 pg. 30-44 increased cortisol levels, promotes weight gain and hinders weight loss efforts [24]. this exacerbates the challenges faced by low-income families. the impact of these disparities is pronounced among hispanic adolescents along the texasmexico border. this region has significant socioeconomic inequalities, with high poverty rates and limited access to healthcare and healthy food options [3]. these inequalities are compounded by cultural factors and acculturation processes. studies have shown that higher levels of assimilation into us culture are associated with decreased consumption of traditional, fiber-rich foods and increased intake of processed foods and sugary drinks, including those containing hfcs [25]. this shift in dietary patterns contributes to higher obesity rates [25]. access to culturally appropriate healthcare and health education is often limited, hindering the ability of hispanic families to address health issues like obesity effectively [3]. accessibility of hfcs-sweetened products the accessibility of hfcs-sweetened products is another critical socioeconomic factor. lowincome neighborhoods often have more convenience stores and fast-food restaurants, major sources of hfcs-sweetened beverages and processed foods [20]. these establishments are often in areas with limited access to supermarkets offering healthier options, creating a food environment that encourages consumption of less nutritious products [20]. aggressive marketing strategies targeting low-income communities promote hfcs-sweetened products that are affordable and appealing to young people [23]. these campaigns often exploit cultural values and preferences, reinforcing consumption among hispanic adolescents and their families [23]. the lack of regulation regarding food advertising in low-income areas exacerbates the problem, creating a food environment that promotes unhealthy eating habits [23]. the cumulative effect is that hfcs-sweetened products are readily available, heavily promoted, and often the most affordable option for low-income families [20]. this creates a substantial barrier to healthy eating and contributes significantly to higher obesity rates in these communities. interventions and public health implications this section examines interventions aimed at reducing hfcs consumption and preventing obesity, focusing on hispanic populations, particularly adolescent females in the texas-mexico border region. the effectiveness of these interventions varies, highlighting the complexity of addressing obesity within specific cultural and socioeconomic contexts. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 36 2024, vol. 4 no. s1 pg. 30-44 many interventions target improvements in physical activity [8], [5] and fruit and vegetable intake [5] through nutrition education, cooking demonstrations, and tastings [5]. however, a family-based intervention targeting obesity-related outcomes in hispanic adolescents showed no significant intervention effects for adolescents' primary outcomes [2].while interventions have improved parents' intake of fresh fruits and vegetables, added sugar, and sweetened beverages, and decreased parents' bmi, these effects weren't sustained long-term [2]. this highlights the need for sustained interventions and potentially booster sessions or increased nutritional information to achieve lasting effects on both parents and adolescents [2]. another study evaluated self-monitored pedometer use among hispanic university students [8]. while the intervention motivated students to reach a 10,000-step count, it didn't significantly improve outcome expectations or address barriers to exercise [8]. this suggests that simply monitoring activity levels may not be sufficient to address the complex factors contributing to obesity in this population. the study also underscores the need for interventions that address both behavioral and environmental factors [8]. research indicates that interventions need to be culturally adapted [5] and acknowledge social determinants of health (sdoh) [5], such as income level, insurance status, and adverse childhood experiences [22], to be effective. a study examining the impact of acculturation on cancer prevention dietary patterns among hispanic families found that participants didn't meet healthy recommendations for cancer prevention regardless of their acculturation and nativity status [6]. this emphasizes the need for interventions that go beyond simply providing nutritional information and address the broader social and cultural contexts that influence dietary choices [6]. the study also showed significant differences in daily dietary intake by acculturation category and nativity status [6], highlighting the importance of tailoring interventions to specific subgroups within the hispanic population [6]. a systematic review and meta-analysis focusing on the effectiveness of healthy lifestyle interventions in obese pediatric patients found that interventions of long duration (at least one year) with an intensive initial phase are needed to produce significant early weight loss in adolescents [26]. the review also highlighted the underrepresentation of hispanics in obesity intervention studies, emphasizing the need for more research tailored specifically to this population [26]. the meta-analysis concluded that lifestyle modifications yielded good outcomes [26], reinforcing the importance of comprehensive interventions that address multiple lifestyle factors [26]. however, the review also acknowledged the limited efficacy, high attrition rates, and waning participant engagement observed in many previous interventions [26], indicating the necessity of developing more engaging and sustainable approaches [26]. the impact of acculturation on dietary intake among hispanic youth needs further investigation. one study found a positive association between the proportion of the hispanic population in a neighborhood and fiber intake and an inverse association with added and total sugar intake [25]. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 37 2024, vol. 4 no. s1 pg. 30-44 however, this protective effect was weaker among youth with higher levels of assimilation [25], suggesting that acculturation may influence dietary choices and the effectiveness of interventions [25]. public health policies play a crucial role in addressing obesity, but their effectiveness varies. policies focusing on reducing soda consumption could contribute to reversing increasing overweight and obesity problems [7]. however, the effectiveness of such policies depends on several factors, including their design, implementation, and enforcement. for example, the impact of sugar-sweetened beverage (ssb) taxes on consumption and obesity remains a subject of ongoing debate [7], with some studies showing modest reductions in consumption [7] while others find minimal effects [7]. additionally, policies aimed at improving access to healthy foods and promoting physical activity are crucial. the availability of convenient stores and healthy food options within a neighborhood can influence dietary choices [20], while policies promoting physical activity in schools and communities can encourage healthier lifestyles [8]. however, the effectiveness of these policies can be influenced by socioeconomic factors and disparities in access to resources [20], [22]. for instance, low-income neighborhoods often lack access to healthy food options and safe spaces for physical activity [20], highlighting the importance of addressing these inequalities through policy interventions [20]. furthermore, educational campaigns aimed at raising awareness of the health risks associated with hfcs consumption and promoting healthier dietary choices are essential. however, the effectiveness of these campaigns depends on their design, targeting, and messaging. studies have shown that providing adolescents with nutrition knowledge and encouraging them to use nutrition labels is associated with healthier dietary behaviors [27]. this suggests that educational interventions should focus on empowering individuals to make informed choices, rather than simply providing information [27]. however, even with such interventions, challenges remain, as highlighted by the fact that adolescents who do not use nutrition labels have significantly greater odds of consuming sugary beverages [27]. the role of family mealtime communication in promoting healthy eating habits among hispanic adolescents should not be overlooked [11]. studies have shown that mealtime communication is associated with fruit and vegetable consumption in boys and physical activity in girls, with single-parent households also impacting dietary consumption [11]. therefore, policies that support and strengthen family structures and promote positive mealtime interactions can play a vital role in promoting healthy eating habits [11]. finally, digital health interventions offer a promising approach for reaching and engaging hispanic adolescents in obesity prevention and management [28]. however, many studies special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 38 2024, vol. 4 no. s1 pg. 30-44 targeting adolescent obesity using digital strategies have not adequately addressed digital health equity criteria, and many have failed to achieve significant bmi reductions [28]. this highlights the need for interventions that are culturally relevant and address the specific needs and challenges of the target population [28]. furthermore, improved reporting of digital health equity criteria is essential to ensure that these interventions are equitable and effective in reducing health disparities [28]. conclusion and future directions addressing the high prevalence of obesity among hispanic adolescent females in the texasmexico border region requires a multi-faceted approach involving comprehensive interventions, effective public health policies, and culturally sensitive strategies. while some interventions have shown promise, the limited long-term success of many interventions and the significant disparities in health outcomes highlight the need for further research and innovative approaches. future research should focus on developing and evaluating interventions that address the complex interplay of biological, behavioral, social, and environmental factors that contribute to obesity in this population. this includes rigorously testing theoretical constructs, family processes, and social determinants of health that influence program participation and health behaviors [5]. furthermore, research should prioritize the inclusion of hispanic adolescents in the design and implementation of interventions to ensure cultural relevance and effectiveness [26], [21]. a stronger emphasis on long-term, intensive interventions, culturally adapted strategies, and addressing socioeconomic factors will be crucial in achieving meaningful and lasting reductions in obesity rates among this vulnerable population. further exploration into the specific mechanisms by which hfcs contributes to obesity in this group is also warranted, potentially using biomarkers to assess habitual added sugar intake [1]. the reviewed studies consistently demonstrate a high prevalence of obesity among hispanic adolescents in the united states, particularly along the texas-mexico border [3], [8]. this elevated risk is linked to various factors including socioeconomic disparities, limited access to healthcare, and insufficient health education [3]. the role of hfcs consumption, a significant component of the diet in this population [12], [15], remains a complex and debated issue. several studies indicate a correlation between increased consumption of sugar-sweetened beverages (ssbs), often containing hfcs, and a higher risk of obesity in adolescents [7], [16], [29]. these beverages contribute significantly to overall daily caloric intake and added sugar consumption, exceeding recommended limits [1]. however, the causal relationship between hfcs and obesity remains inconclusive [14], [30]. many studies suffer from methodological limitations, including reliance on self-reported dietary data, short follow-up periods, and inadequate consideration of confounding factors such as overall dietary patterns and lifestyle special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 39 2024, vol. 4 no. s1 pg. 30-44 choices [14], [30], [2]. furthermore, the metabolic effects of hfcs may differ from sucrose, though the exact nature and extent of these differences are still under investigation [14], [13]. furthermore, the impact of hfcs extends beyond simple weight gain. studies suggest potential links between hfcs consumption and adverse metabolic outcomes, including increased triglyceride levels and insulin resistance [16], [19]. there is also some evidence suggesting a correlation between hfcs and neuropsychiatric effects [31], though these findings require further exploration. the existing research has not adequately examined the potential interactions between hfcs consumption and other factors contributing to obesity risk in hispanic adolescent females, such as acculturation, family dynamics, and access to healthy food options [25], [6], [11]. moreover, the influence of neighborhood environment and socioeconomic status on both hfcs consumption and obesity prevalence is not fully understood [20], [3]. the limited research specifically focusing on hispanic adolescent females in the texas-mexico border region further complicates the interpretation of findings. the unique cultural and socioeconomic context of this population demands tailored research approaches that consider these specific factors [26]. studies employing culturally appropriate methodologies and community engagement strategies are needed to better understand the complex interplay of factors influencing obesity risk in this group [5], [21]. longitudinal studies with objective measures: longitudinal studies using objective measures of dietary intake and body composition are crucial to establish a causal relationship between hfcs consumption and obesity. biomarkers, such as the delta (δ) 13c biomarker [1], offer a more accurate assessment of added sugar intake than self-reported data. these studies should follow participants for an extended period to capture long-term effects. such research should also account for potential interactions between hfcs intake and other dietary factors , [6]. culturally relevant interventions: future research should focus on developing and evaluating culturally relevant interventions to reduce hfcs consumption and promote healthier dietary patterns. interventions must consider the unique cultural context of the texas-mexico border region [5], [21]. community-based participatory research (cbpr) approaches are essential to ensure interventions are acceptable, accessible, and effective [26]. these interventions should address dietary changes and broader lifestyle factors. exploration of underlying mechanisms: further research is needed to elucidate the underlying mechanisms by which hfcs consumption contributes to obesity. this includes investigating the potential impact of hfcs on gut microbiota composition and function [18], its effects on appetite regulation and satiety [17], and its interaction with other metabolic pathways [24], [19]. understanding these mechanisms will provide crucial insights into the development of more effective prevention and treatment strategies. furthermore, research should investigate the special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 40 2024, vol. 4 no. s1 pg. 30-44 potential role of genetic factors that may influence the susceptibility of hispanic individuals to the adverse effects of hfcs consumption [4]. addressing socioeconomic disparities: research should address the social determinants of health (sdoh) [20], [5]. studies should investigate how factors such as income level, access to healthy food options, and neighborhood characteristics influence both hfcs consumption and obesity risk [32]. this understanding will inform the development of interventions that target these upstream determinants of health inequities. furthermore, the potential influence of acculturation on dietary patterns and obesity risk needs to be further explored [25], [6]. multi-level interventions: multi-level interventions addressing individual, family, community, and policy levels are crucial. individual-level interventions could focus on nutrition education, behavior modification techniques, and personalized dietary guidance. family-level interventions could involve family-based counseling, cooking classes, and strategies to promote healthy eating habits at home [2], [11]. community-level interventions could focus on improving access to healthy food options, creating supportive environments for physical activity, and promoting community-wide initiatives to reduce hfcs consumption [20]. policy-level interventions could involve taxation of ssbs, regulations on marketing of unhealthy foods to children, and policies to improve access to affordable, healthy foods [7]. the effectiveness of multi-level interventions should be rigorously evaluated through randomized controlled trials (rcts) [28]. data collection and analysis refinements: future research should address the methodological limitations of previous studies. this includes using standardized definitions and measurement tools for dietary intake, body composition, and other relevant outcomes. moreover, rigorous statistical analyses should be employed to control for confounding variables and assess potential effect modification [14], [30]. the use of large, population-based datasets can provide valuable insights, facilitating robust statistical analyses by addressing these research gaps and utilizing rigorous methodologies, future studies can provide a more complete understanding of hfcs's role in obesity among hispanic adolescent females in the texas-mexico border region. this improved understanding will enable the development and implementation of effective, culturally relevant interventions to improve the health outcomes of this vulnerable population. acknowledgements: nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 41 2024, vol. 4 no. s1 pg. 30-44 funding: funded by dhr health high school and community outreach; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. macdougall cr, hill ce, jahren ah, et al. the δ13c value of fingerstick blood is a valid, reliable, and sensitive biomarker of sugar-sweetened beverage intake in children and adolescents. the journal of nutrition. 2018;148(1):147-152. doi:https://doi.org/10.1093/jn/nxx017 2. cross aj, elliott ra, petrie k, kuruvilla l, george j. interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications. cochrane database of systematic reviews. 2020;5(5). doi:https://doi.org/10.1002/14651858.cd012419.pub2 3. salinas j, sheen j, carlyle m, et al. using electronic medical record data to better understand obesity in hispanic neighborhoods in el paso, texas. international journal of environmental research and public health. 2020;17(12):4591. doi:https://doi.org/10.3390/ijerph17124591 4. basu t, ujala sehar, selman a, reddy ap, p. hemachandra reddy. support provided by caregivers for community-dwelling obesity individuals: focus on elderly and hispanics. healthcare. 2023;11(10):1442-1442. doi:https://doi.org/10.3390/healthcare11101442 5. soltero eg, peña a, gonzalez v, et al. family-based obesity prevention interventions among hispanic children and families: a scoping review. nutrients. 2021;13(8):2690. doi:https://doi.org/10.3390/nu13082690 6. lovan p, boga d, messiah se, lee t, benzo rm, prado g. impact of acculturation on cancer prevention dietary patterns among hispanic families with a high prevalence of obesity. nutrition and cancer. published online august 18, 2022:1-11. doi:https://doi.org/10.1080/01635581.2022.2112242 7. babey sh, jones m, yu h, goldstein h. bubbling over: soda consumption and its link to obesity in california. policy brief (ucla center for health policy research). 2009;(pb2009-5):1-8. accessed july 26, 2021. https://pubmed.ncbi.nlm.nih.gov/19768858/ 8. myers, d. l., romero, z., anzaldua, n., & trinidad, m. l. (2011). exercise intervention at a hispanic-serving institution. college student journal, 45(2), 428–438. 9. smith js, berkel c, rudo-stern j, et al. the family check-up 4 health (fcu4health): applying implementation science frameworks to the process of adapting an evidencebased parenting program for prevention of pediatric obesity and excess weight gain in https://doi.org/10.1093/jn/nxx017 https://doi.org/10.1002/14651858.cd012419.pub2 https://doi.org/10.3390/ijerph17124591 https://doi.org/10.3390/healthcare11101442 https://doi.org/10.3390/nu13082690 https://doi.org/10.1080/01635581.2022.2112242 https://pubmed.ncbi.nlm.nih.gov/19768858/ special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 42 2024, vol. 4 no. s1 pg. 30-44 primary care. frontiers in public health. 2018;6. doi:https://doi.org/10.3389/fpubh.2018.00293 10. vidmar ap, jones rb, wee cp, et al. timing of food consumption in hispanic adolescents with obesity. pediatric obesity. 2020;16(7). doi:https://doi.org/10.1111/ijpo.12764 11. lebron cn, agosto y, lee tk, et al. family mealtime communication in singleand dual-headed households among hispanic adolescents with overweight and obesity. journal of nutrition education and behavior. 2020;52(9):840-849. doi:https://doi.org/10.1016/j.jneb.2020.03.003 12. hein gl, storey ml, white js, lineback dr. highs and lows of high fructose corn syrup: a report from the center for food and nutrition policy and its ceres(r) workshop. nutrition today. 2005;40(6):253-256. https://www.researchgate.net/publication/232202859_highs_and_lows_of_high_fructo se_corn_syrup_a_report_from_the_center_for_food_and_nutrition_policy_and_its_ ceresr_workshop 13. mennella ja, bobowski nk. the sweetness and bitterness of childhood: insights from basic research on taste preferences. physiology & behavior. 2015;152:502-507. doi:https://doi.org/10.1016/j.physbeh.2015.05.015 14. livesey g. fructose, obesity, and related epidemiology. critical reviews in food science and nutrition. 2010;50(sup1):26-28. doi:https://doi.org/10.1080/10408398.2010.526870 15. vos mb, kimmons je, gillespie c, welsh j, blanck hm. dietary fructose consumption among us children and adults: the third national health and nutrition examination survey. the medscape journal of medicine. 2008;10(7):160. accessed january 6, 2025. https://pmc.ncbi.nlm.nih.gov/articles/pmc2525476/ 16. chan tf, lin wt, chen yl, et al. elevated serum triglyceride and retinol-binding protein 4 levels associated with fructose-sweetened beverages in adolescents. tomé d, ed. plos one. 2014;9(1):e82004. doi:https://doi.org/10.1371/journal.pone.0082004 17. maj m, harbottle b, thomas pa, et al. consumption of high-fructose corn syrup compared with sucrose promotes adiposity and increased triglyceridemia but comparable nafld severity in juvenile iberian pigs. the journal of nutrition. 2021;151(5):1139-1149. doi:https://doi.org/10.1093/jn/nxaa441 18. hsu tm, konanur vr, taing l, et al. effects of sucrose and high fructose corn syrup consumption on spatial memory function and hippocampal neuroinflammation in adolescent rats. hippocampus. 2014;25(2):227-239. doi:https://doi.org/10.1002/hipo.22368 19. johnson ka, showell nn, flessa s, et al. do neighborhoods matter? a systematic review of modifiable risk factors for obesity among low socio-economic status black and hispanic children. childhood obesity. 2019;15(2):71-86. doi:https://doi.org/10.1089/chi.2018.0044 https://doi.org/10.3389/fpubh.2018.00293 https://doi.org/10.1111/ijpo.12764 https://doi.org/10.1016/j.jneb.2020.03.003 https://www.researchgate.net/publication/232202859_highs_and_lows_of_high_fructose_corn_syrup_a_report_from_the_center_for_food_and_nutrition_policy_and_its_ceresr_workshop https://www.researchgate.net/publication/232202859_highs_and_lows_of_high_fructose_corn_syrup_a_report_from_the_center_for_food_and_nutrition_policy_and_its_ceresr_workshop https://www.researchgate.net/publication/232202859_highs_and_lows_of_high_fructose_corn_syrup_a_report_from_the_center_for_food_and_nutrition_policy_and_its_ceresr_workshop https://doi.org/10.1016/j.physbeh.2015.05.015 https://doi.org/10.1080/10408398.2010.526870 https://pmc.ncbi.nlm.nih.gov/articles/pmc2525476/ https://doi.org/10.1371/journal.pone.0082004 https://doi.org/10.1093/jn/nxaa441 https://doi.org/10.1002/hipo.22368 https://doi.org/10.1089/chi.2018.0044 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 43 2024, vol. 4 no. s1 pg. 30-44 20. arubuolawe oo, gabriel ot, anats cj, et al. demographic and socioeconomic disparities in adolescent obesity: insights from the national survey of children’s health database. cureus. published online october 22, 2024. doi:https://doi.org/10.7759/cureus.72150 21. fan jx, brown bb, kowaleski-jones l, smith kr, zick cd. household food expenditure patterns: a cluster analysis. monthly labor review / us department of labor, bureau of labor statistics. 2007;130(4):38-50. https://www.researchgate.net/publication/289417545_household_food_expenditure_patt erns_a_cluster_analysis 22. kageyama i, yamada h, munetsuna e, et al. differential effects of excess high-fructose corn syrup on the dna methylation of hippocampal neurotrophic factor in childhood and adolescence. hetman m, ed. plos one. 2022;17(6):e0270144. doi:https://doi.org/10.1371/journal.pone.0270144 23. fred wen ck, hsieh s, huh j, et al. the role of assimilating to the us culture and the relationship between neighborhood ethnic composition and dietary intake among hispanic youth. journal of racial and ethnic health disparities. 2016;4(5):904-910. doi:https://doi.org/10.1007/s40615-016-0293-1 24. zuñiga am, jaramillo ap. the effectiveness of a healthy lifestyle in obese pediatric patients: a systematic review and meta-analysis. curēus. published online november 8, 2023. doi:https://doi.org/10.7759/cureus.48525 25. haidar a, carey fr, ranjit n, archer n, hoelscher d. self-reported use of nutrition labels to make food choices is associated with healthier dietary behaviours in adolescents. public health nutrition. 2017;20(13):2329-2339. doi:https://doi.org/10.1017/s1368980017001252 26. partridge sr, knight a, todd a, et al. addressing disparities: a systematic review of digital health equity for adolescent obesity prevention and management interventions. obesity reviews. published online september 10, 2024. doi:https://doi.org/10.1111/obr.13821 27. haftoglou s. relationship between sugar sweetened beverage consumption and academic performance among elementary and middle school children. escholarship.org. published 2015. accessed january 6, 2025. https://escholarship.org/uc/item/9n93f72k 28. cerini c, mameli c, zuccotti gv. soft drinks and obesity in children: an intricate puzzle. expert review of endocrinology & metabolism. 2013;8(1):5-7. doi:https://doi.org/10.1586/eem.12.70 29. alten b, yesiltepe m, bayraktar e, et al. high-fructose corn syrup consumption in adolescent rats causes bipolar-like behavioural phenotype with hyperexcitability in hippocampal ca3-ca1 synapses. british journal of pharmacology. 2018;175(24):4450-4463. doi:https://doi.org/10.1111/bph.14500 https://doi.org/10.7759/cureus.72150 https://www.researchgate.net/publication/289417545_household_food_expenditure_patterns_a_cluster_analysis https://www.researchgate.net/publication/289417545_household_food_expenditure_patterns_a_cluster_analysis https://doi.org/10.1371/journal.pone.0270144 https://doi.org/10.1007/s40615-016-0293-1 https://doi.org/10.7759/cureus.48525 https://doi.org/10.1017/s1368980017001252 https://doi.org/10.1111/obr.13821 https://escholarship.org/uc/item/9n93f72k https://doi.org/10.1586/eem.12.70 https://doi.org/10.1111/bph.14500 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.3 dhr proceedings ǀ http://dhrproceedings.org 44 2024, vol. 4 no. s1 pg. 30-44 30. o’lawrence h, martinez l, castelo g, humes e, mayorga b, rosas s. the latest review of childhood obesity among hispanic and latinx populations in california. diabetes research: open access. 2020;2(2):22-30. doi:https://doi.org/10.36502/2020/droa.6165 https://doi.org/10.36502/2020/droa.6165 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 15 2024, vol. 4 no. s1 pg. 15-29 manuscript socioeconomic barriers to health outcomes in hispanic populations impact by fentanyl along the texas-mexico border marisol acosta1, sarah colunga1,2, ashlyn gonzalez1,3, alexsandra longoria1,3,4, sophia mina1,5, rebecca saenz1,6, joselyn salinas1, 7, madison thomas1, 8, joncarlo rodriguez1,9 1dhr health high school and community outreach 2 monte alto high school 3 south texas isd world scholars 4 jubilee academies 5 idea toros college preparatory 6 rio hondo isd 7 la joya isd 8 mcallen isd 9 lasara isd received: july 12, 2024 accepted for publication: january 6, 2025 introduction this literature review examines the challenges of addressing socioeconomic barriers to health outcomes in hispanic populations impacted by fentanyl along the texas-mexico border. this vulnerable population faces converging factors that exacerbate fentanyl use risks and hinder access to effective interventions. the texas-mexico border region, a unique binational environment, presents a complex interplay of social, economic, and cultural influences shaping health outcomes. this review explores three key areas: health disparities among hispanic populations along the texas-mexico border, the importance of addressing socioeconomic barriers, and fentanyl’s specific health impact within this demographic. this exploration will highlight the interconnectedness of these factors and underscore the need for comprehensive, culturally sensitive, and community-based approaches to mitigate fentanyl's devastating consequences in this region. health disparities and socioeconomic barriers this section examines the interplay of health disparities and socioeconomic barriers impacting health outcomes for hispanic populations along the texas-mexico border, particularly concerning rising fentanyl use. this region presents converging vulnerabilities: poverty, limited healthcare access, cultural and linguistic barriers, and navigating a binational context. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 16 2024, vol. 4 no. s1 pg. 15-29 understanding these multifaceted challenges is crucial for developing effective interventions and policies to mitigate the fentanyl crisis’s devastating effects on this population. socioeconomic factors and health outcomes socioeconomic factors powerfully shape health outcomes within hispanic communities along the texas-mexico border [1]. poverty and lower educational attainment [2] limit access to resources promoting well-being. financial constraints restrict access to nutritious food, safe housing, and reliable transportation [3], contributing to chronic health conditions and increased substance use vulnerability. limited english proficiency creates communication barriers, hindering effective healthcare utilization [4]. these intersecting factors disproportionately impact hispanic communities. for instance, a study of hispanic manufacturing workers along the border found a strong association between lack of health insurance, delayed medical care, unmet medical needs, and lower preventive service rates (flu vaccination and cervical cancer screening) [5]. this highlights how economic insecurity directly translates into poorer health outcomes. barriers to healthcare access accessing quality healthcare remains a significant challenge for hispanic populations along the texas-mexico border [6]. several factors contribute to this disparity, including a shortage of healthcare providers, particularly in rural areas [2]. many border counties report some of the worst us health disparity statistics, including limited access to quality healthcare and lower cancer screening rates [7]. lack of insurance exacerbates this, leaving many unable to afford essential medical services [5]. a study of breast cancer incidence and survival along the border found that while adjusted survival rates were similar or even better for hispanic women in some cases, disparities persisted in diagnosis and treatment access [7]. this underscores addressing the entire continuum of care, from prevention and early detection to treatment and long-term management. even when insured, navigating the healthcare system can be daunting, especially with limited english proficiency [4]. cultural factors, like traditional health beliefs and practices [8], can influence healthcare-seeking behaviors and create additional barriers to mainstream medical services. education, employment, and health education and employment are crucial pathways to improved health access and outcomes [3]. higher education correlates with increased health literacy, empowering informed decisions, and more effective healthcare system navigation [4]. stable employment provides health insurance access, which is critical for timely medical care and preventive services [5]. however, many hispanic individuals along the border face education and employment challenges. lower educational attainment limits job opportunities, perpetuating a cycle of poverty and poor health [2]. many regional employment opportunities offer low wages and limited benefits [5], leaving workers vulnerable to economic instability and without resources for quality healthcare. a study exploring acculturation and healthy lifestyle habits in border communities found a complex special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 17 2024, vol. 4 no. s1 pg. 15-29 interplay between cultural adaptation and health behaviors [3]. less acculturated individuals reported healthier dietary habits but were less likely to engage in regular physical activity, highlighting the need for culturally sensitive health promotion programs considering the unique context of border communities. this complex landscape of socioeconomic barriers and health disparities creates a significant challenge for addressing the fentanyl crisis within hispanic communities along the texas-mexico border. fentanyl crisis in hispanic communities the fentanyl crisis disproportionately impacts vulnerable communities, including hispanic populations along the texas-mexico border. this section examines the intersection of socioeconomic factors, fentanyl use, and public health implications within this demographic. it analyzes fentanyl use’s devastating impact, explores the correlation between socioeconomic status and fentanyl-related health issues, and identifies specific overdose trends among hispanic border populations. analysis of fentanyl use and its implications on public health fentanyl, a synthetic opioid significantly more potent than heroin [9], has infiltrated drug supplies, dramatically increasing overdose risks. escalating fentanyl-related overdose deaths underscores the urgent need for targeted interventions [9]. while the opioid crisis initially stemmed from prescription opioid misuse, it now includes increased illicitly manufactured fentanyl availability [9]. this shift has broadened the crisis, reaching beyond individuals with prior prescription opioid dependence to encompass broader populations, including hispanic communities along the texas-mexico border. with its unique binational environment [6], this border presents particular challenges to healthcare access, especially for vulnerable populations. the region's high poverty rate, increased prevalence of birth defects, and limited access to genetic services [10] exacerbate existing health disparities. these factors create a context where the fentanyl crisis can flourish, exploiting pre-existing vulnerabilities. the public health implications of fentanyl use are multifaceted. increased mortality rates due to overdose are a primary concern. beyond mortality, fentanyl use leads to other health complications: severe respiratory depression, neurological damage, and increased risk of infectious diseases like hiv and hepatitis c [11]. these consequences strain healthcare systems, particularly in resource-limited border regions. the fentanyl crisis often overlaps with other health disparities prevalent in hispanic communities, such as diabetes and cardiovascular disease [12], complicating treatment and prevention. correlation between socioeconomic status and fentanyl-related health issues socioeconomic factors crucially shape vulnerability to fentanyl use and its associated health consequences. lower socioeconomic status is associated with increased substance use disorder risk, including opioid addiction [13]. poverty, limited educational opportunities, and lacking special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 18 2024, vol. 4 no. s1 pg. 15-29 healthcare access [4] create a vulnerability cycle predisposing individuals to substance use and hindering access to treatment and recovery services. along the texas-mexico border, these socioeconomic disparities are compounded by immigration status and language barriers [6], further limiting access to essential health services. for example, uninsured individuals are more likely to delay seeking medical care and face financial barriers to needed services [5]. this delay can be detrimental to a fentanyl overdose, where timely medical intervention is crucial. the lack of health insurance among many hispanic manufacturing workers along the border further restricts preventive health services access and contributes to delayed medical care [5]. poverty significantly impacts health outcomes in border communities, influencing healthcare, education, and basic resource access [2]. these factors interact to create a complex web of vulnerability, increasing fentanyl use and related health issue risks. webb county, texas, residents, for instance, experience health disparities stemming from extreme poverty and inadequate healthcare access, including scarce primary care and behavioral health services [2]. this limited access creates significant barriers to effectively addressing the fentanyl crisis within these communities. trends in fentanyl-related overdoses among hispanic populations data indicate a concerning trend of increasing fentanyl-related overdoses among hispanic populations, particularly along the texas-mexico border [7]. while national trends show declining colorectal cancer (crc) incidence among hispanics, the decline is less pronounced than other racial/ethnic groups, particularly among hispanic men residing near the us-mexico border [14]. this suggests border proximity contributes to health outcome disparities. the increasing prevalence of fentanyl in the drug supply is a major driver, as even small amounts can be lethal [15]. the covid-19 pandemic has exacerbated existing health disparities and socioeconomic vulnerabilities [16], potentially contributing to increased substance use and overdose rates. analyzing texas cancer registry data reveals a complex interplay of factors influencing breast cancer incidence and survival among hispanic women [7]. while some studies report later diagnosis and worse outcomes in this population, research also indicates potential protective factors among women residing in border counties, particularly those in lower poverty levels [7]. further investigation is needed to understand these complex trends and identify specific interventions to address the fentanyl crisis effectively within hispanic communities along the border. the ongoing avanzando caminos cohort study explores multifaceted factors influencing cancer survivorship among hispanics/latinos, including sociocultural, medical, psychosocial, and biological factors [17]. this research may provide valuable insights into the interplay between cancer survivorship, socioeconomic factors, and substance use, including fentanyl, within this population. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 19 2024, vol. 4 no. s1 pg. 15-29 community health initiatives this section examines community health initiatives along the texas-mexico border addressing socioeconomic barriers contributing to fentanyl-related health outcomes in the hispanic population. it explores existing programs mitigating health disparities, evaluates communitybased interventions’ effectiveness in improving care access, and highlights promotoras’ (community health workers) role in outreach and education. overview of programs addressing health disparities the texas-mexico border region faces significant health disparities due to poverty, limited healthcare access, and cultural and linguistic barriers [6]. several programs and initiatives tackle these challenges. the alliance for a healthy border reduces health disparities through nutrition and physical activity education programs at community health centers [3]. project give (genetic inclusion by virtual evaluation) utilizes a virtual telehealth platform to provide genetic services to underserved rio grande valley families, shortening the diagnostic journey for children with rare diseases [10]. mercy ministries of laredo integrated primary, behavioral, and spiritual healthcare to improve patient outcomes in webb county, a region characterized by extreme poverty and limited healthcare access [2]. stop-hcc-hcv is a multi-component intervention that increases access to hepatitis c virus (hcv) screening and treatment in lowincome south texas hispanic communities [18]. these initiatives demonstrate diverse approaches to addressing border health disparities. additionally, initiatives like the border health strategic initiative focus on community-based solutions for type 2 diabetes control through community engagement and collaboration between communities and researchers [19]. this participatory approach is also evident in the racial and ethnic approaches to community health (reach) 2010 communities, which focus on eliminating health disparities [19]. while these programs target specific health issues, their underlying principles of community engagement and collaboration are relevant to addressing the fentanyl crisis. effectiveness of community-based interventions community-based interventions are crucial for improving care access, particularly for vulnerable populations facing socioeconomic barriers [5]. one successful example is the promotoras program, utilizing community health workers to provide education, address barriers, and increase preventive care service access [20]. studies demonstrate promotoras’ effectiveness in improving cervical cancer, pap tests, and hpv knowledge and awareness [20]. they effectively change attitudes, increase self-efficacy, and promote routine pap test screening [20]. this communitybased healthcare delivery model can be adapted for fentanyl-related interventions. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 20 2024, vol. 4 no. s1 pg. 15-29 community health centers are vital in providing primary care and other essential health services to underserved populations [3]. as demonstrated by mercy ministries of laredo, integrating primary, behavioral, and spiritual health care significantly improves patient outcomes, including quality of life and anxiety symptoms [2]. integrating fentanyl-related services into existing community health centers could enhance harm reduction and treatment service access. virtual telehealth platforms, like project give's [10], offer another avenue for reaching medically underserved populations and overcoming socioeconomic barriers to accessing genetic services. this approach could provide fentanyl-related education, counseling, and treatment services remotely. role of promotoras in outreach and education promotoras, as trusted community members [20], bridge the gap between healthcare providers and the hispanic population. their cultural understanding and linguistic skills enable effective health information communication and address cultural sensitivities [4]. studies have shown their success in improving health outcomes through culturally tailored interventions [8]. regarding the fentanyl crisis, promotoras can raise awareness about fentanyl’s dangers, promote harm reduction strategies like naloxone distribution, and connect individuals with treatment resources. they can address stigma surrounding substance use disorders and encourage helpseeking behavior. promotoras’ effectiveness extends beyond individual-level interventions. they can mobilize community resources and advocate for policy changes addressing the fentanyl crisis’s root causes, like poverty and lacking healthcare access. by empowering community members with knowledge and resources, promotoras contribute to healthier, more resilient communities. given their established success in other health initiatives, promotoras should be central to any comprehensive strategy addressing the fentanyl crisis among hispanic border populations. their cultural sensitivity, community ties, and ability to navigate complex social systems make them invaluable in reaching and serving this vulnerable population. policy implications this section analyzes policy implications stemming from socioeconomic factors and fentanyl’s devastating impact on hispanic border communities. it reviews current health policies affecting these populations, proposes policy change recommendations, and emphasizes integrating socioeconomic considerations into health policy. current health policies and their impact existing border health policies are often fragmented and inadequately address hispanic communities’ unique challenges. while the affordable care act (aca) expanded insurance coverage, significant gaps remain, especially among undocumented immigrants and those in low-wage jobs with limited benefits [5]. this lack of insurance directly impacts preventive care, special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 21 2024, vol. 4 no. s1 pg. 15-29 early diagnosis, and substance use disorder treatment access [5]. limited culturally and linguistically appropriate healthcare services exacerbate disparities [11]. while some policies focus on border security [6], they often inadequately address the public health crisis fueled by fentanyl trafficking, hindering effective interventions. the scarcity of primary care and behavioral health providers in border communities restricts access to essential services for individuals struggling with opioid addiction [2]. current policies also lack comprehensive strategies for addressing underlying socioeconomic factors contributing to substance use vulnerability, such as poverty, limited educational opportunities, and employment lack [3]. recommendations for policy changes combating the fentanyl crisis and improving hispanic border population health outcomes requires comprehensive policy changes. enhancing healthcare access: expanding affordable healthcare access is paramount. policies should prioritize extending medicaid eligibility to all low-income individuals regardless of immigration status, ensuring access to comprehensive health services, including substance use disorder treatment [5]. increased funding for community and federally qualified health centers is essential for providing culturally and linguistically competent primary care and behavioral health services in underserved border communities [2]. telehealth initiatives can expand healthcare service reach to remote areas and reduce transportation barriers [10]. policies should address the healthcare provider shortage by incentivizing physicians and other healthcare professionals to practice in underserved border regions and supporting training programs focused on cultural competency and substance use disorder treatment [2]. reducing health disparities: policies must be tailored to hispanic communities’ needs. culturally and linguistically appropriate public health campaigns are crucial for raising awareness about fentanyl dangers and promoting prevention and treatment service access [11]. community-based interventions, like the promotoras program [20], have shown promise in increasing health knowledge and improving preventive care access among hispanic women. similar models can be adapted for fentanyl prevention and intervention efforts. policies should prioritize addressing social determinants of health that contribute to disparities. this includes investing in programs promoting economic development, improving educational opportunities, and increasing safe and affordable housing access in border communities [3]. collaborations between healthcare systems, social service agencies, and community organizations are essential for providing wraparound services addressing the multifaceted needs of individuals and families impacted by fentanyl. addressing fentanyl trafficking: a comprehensive approach to the fentanyl crisis necessitates addressing the supply side. strengthening cross-border collaboration with mexican authorities is crucial for disrupting fentanyl trafficking networks and reducing drug availability in border communities [6]. increased funding for law enforcement efforts targeting drug trafficking is special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 22 2024, vol. 4 no. s1 pg. 15-29 necessary, but it should be coupled with public health interventions focusing on prevention, treatment, and harm reduction. policies should prioritize addressing fentanyl demand by expanding access to evidence-based treatment for opioid use disorder and supporting harm reduction strategies, such as naloxone distribution programs, which can save lives during overdoses [9]. integrating socioeconomic considerations: health policies must move beyond a purely biomedical approach and incorporate a comprehensive understanding of socioeconomic factors influencing health outcomes. policies should prioritize investments in social programs addressing poverty, lack of education, and unemployment, recognizing these factors contribute to vulnerability to substance use and other health problems [3]. data collection and surveillance systems should be strengthened to track socioeconomic factors' impact on health outcomes and evaluate intervention effectiveness. policies should promote community-based participatory research, engaging hispanic communities in identifying their needs and developing culturally appropriate solutions [10]. the importance of integrating socioeconomic considerations integrating socioeconomic considerations into health policy is not simply social justice but pragmatically necessary for effectively addressing the fentanyl crisis and improving health outcomes. studies consistently show socioeconomic factors, such as poverty, limited education, and unemployment, are strongly associated with increased substance use disorder risk, poorer health outcomes, and higher mortality rates [21]. neglecting these factors leads to ineffective policies that fail to address the root causes of health disparities. by incorporating socioeconomic considerations, policies can be tailored to vulnerable populations’ specific needs, promoting health equity and improving overall population health. furthermore, addressing socioeconomic factors can lead to long-term cost savings by reducing healthcare utilization and enhancing productivity. investing in early childhood education and job training programs can significantly impact long-term health and economic outcomes [3]. integrating socioeconomic considerations into health policy is crucial to a healthier and more equitable society. this integration requires a multi-sectoral approach involving collaboration between healthcare systems, social service agencies, educational institutions, and community organizations. by working together, these entities can create a comprehensive support network addressing the complex needs of individuals and families impacted by fentanyl and other health challenges. ongoing policy evaluation and adaptation are essential to ensure their relevance and effectiveness in addressing the evolving needs of border communities. the fentanyl crisis presents a significant challenge but also an opportunity to create innovative and transformative policies promoting health equity and improving all border residents’ well-being. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 23 2024, vol. 4 no. s1 pg. 15-29 future research directions this review explored the complex interplay of socioeconomic barriers and fentanyl’s devastating impact on hispanic border populations. while existing research illuminates certain aspects of this public health crisis, significant gaps hinder effective intervention and policy development. this section outlines crucial future research directions to address this urgent issue comprehensively. identifying gaps in current research acknowledging and addressing existing gaps in our understanding of socioeconomic factors exacerbating the fentanyl crisis among hispanic border communities is critical. while studies have examined health disparities in this region [6] [22], focusing on diabetes [12] [23], cancer [24] [7] [14], and hiv [11], research explicitly targeting the intersection of socioeconomic vulnerabilities and fentanyl use remains limited. further investigation is needed to understand this population’s unique challenges fully. acculturation’s role in health behaviors [3] needs further exploration in the context of fentanyl use, as do the specific socioeconomic factors influencing healthcare service access and utilization [5]. research should examine how limited english proficiency [25], poverty [2], and lack of health insurance [5] contribute to increased fentanyl use and overdose vulnerability. research on existing intervention effectiveness, such as those using community health workers (promotoras) [20], should expand to include fentanyl prevention and harm reduction. future studies on health interventions building upon identified research gaps, future studies should prioritize developing and evaluating culturally tailored health interventions for hispanic populations impacted by fentanyl along the border. these interventions must consider the region’s unique cultural context and address the identified socioeconomic barriers. one promising approach is using technology, such as mobile health (mhealth) interventions [26], to deliver education and support for individuals with chronic conditions like diabetes, adaptable for fentanyl prevention and harm reduction. research should explore integrating primary, behavioral, and spiritual healthcare [2] into interventions addressing substance use disorders, recognizing their potential synergistic effects. given the documented disparities in cancer treatment and outcomes among hispanic populations [7] [24], future studies should investigate fentanyl use’s impact on cancer survivorship and explore interventions mitigating these detrimental effects. studies are needed to examine the effectiveness of community-based interventions leveraging existing resources and social networks [19]. finally, given the significant border health disparities [6] [8], research should assess cross-border collaboration feasibility and effectiveness in addressing the fentanyl crisis. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 24 2024, vol. 4 no. s1 pg. 15-29 multi-disciplinary approaches the fentanyl crisis’s complexity demands multi-disciplinary approaches integrating perspectives from public health, medicine, social work, economics, and law enforcement. cross-discipline collaboration can lead to more comprehensive and effective interventions addressing fentanyl use and overdose root causes. researchers could collaborate with community organizations to implement and evaluate interventions addressing socioeconomic factors and treatment access. researchers studying rare genetic diseases in medically underserved hispanic populations [10] demonstrated community engagement’s effectiveness in overcoming healthcare access barriers, offering a valuable model for future fentanyl-related research. multi-disciplinary research can inform local, state, and national policy development. studies examining socioeconomic factors’ impact on health outcomes [13] [27] can provide valuable insights for policymakers addressing health disparities. given the documented disparities in melanoma immunotherapy access [28], multi-disciplinary research can identify strategies ensuring equitable access to life-saving treatments. finally, collaboration between researchers, healthcare providers, and community members can develop culturally sensitive and sustainable solutions to the fentanyl crisis. this collaborative approach could address socioeconomic barriers [29], improve care access, and promote health equity for hispanic border populations. further “hispanic paradox” exploration [15] [30] within the fentanyl crisis context is needed to understand potential protective factors and community resilience. research exploring race, ethnicity, and country of origin effects on cancer incidence and survival [24] can inform more tailored interventions for hispanic subgroups. finally, given the documented hepatocellular carcinoma burden among south texas hispanics [31], future research should investigate the potential link between fentanyl use and liver cancer risk. conclusion this review explored the intricate challenges surrounding socioeconomic barriers to health outcomes among hispanic populations impacted by fentanyl along the texas-mexico border. this border region presents a unique confluence of factors exacerbating the fentanyl crisis: socioeconomic disparities, limited healthcare access, cultural nuances, and cross-border interaction complexities. this conclusion synthesizes key findings, reinforces the urgent need for targeted interventions, and offers final reflections on addressing socioeconomic barriers’ critical importance in improving this vulnerable population’s health outcomes. socioeconomic disparities and healthcare access a recurring theme is socioeconomic disparities' significant influence on health outcomes in the texas-mexico border region. poverty, lower educational attainment, and inadequate access to basic healthcare services disproportionately affect hispanic communities [2]. these disparities create vulnerability to various health issues, including substance use disorders. lack of health insurance is a significant barrier to accessing necessary medical care, including preventative special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 25 2024, vol. 4 no. s1 pg. 15-29 services and substance abuse treatment [5]. uninsured individuals are more likely to delay or forgo necessary services due to cost [5]. this can have devastating consequences with fentanyl use, where timely intervention can be life-saving. limited specialized care access, such as addiction treatment and mental health services, further compounds challenges faced by hispanic populations struggling with fentanyl use [10]. project give demonstrates virtual platforms’ potential to address geographic barriers and expand genetic service access in underserved regions [10]. this innovative approach demonstrates leveraging technology to improve marginalized communities’ healthcare access, adaptable for substance abuse treatment. cultural factors and community engagement cultural factors crucially shape health behaviors and responses to interventions. culturally sensitive healthcare approaches are important, as evident in several studies [4]. language barriers, cultural beliefs, and traditional practices can influence healthcare utilization and treatment adherence [4]. effective interventions must consider these cultural nuances to ensure relevance and acceptability within hispanic communities. community engagement and partnerships are essential for developing and implementing successful programs [10]. engaging community members, including community health workers (promotoras), can bridge cultural gaps and build trust between healthcare providers and the community [20]. promotoras, as trusted community members, can disseminate health information, promote healthy behaviors, and facilitate healthcare service access [20]. their involvement can enhance intervention effectiveness and ensure cultural appropriateness. fentanyl's impact and targeted interventions fentanyl’s devastating impact on hispanic border communities is undeniable. increasing fentanyl-related overdoses and deaths underscore the urgency of addressing this crisis [9]. the border region’s unique characteristics, including easy drug trafficking and transnational criminal organizations’ presence, contribute to fentanyl’s availability and accessibility [9]. targeted interventions are crucial to combat the fentanyl epidemic and mitigate its devastating effects on hispanic populations. these interventions must address substance use’s root causes, including socioeconomic factors, mental health issues, and lacking treatment access. harm reduction strategies, such as naloxone distribution and safe injection sites, can save lives and reduce harmful consequences associated with fentanyl use [9]. expanding access to evidence-based treatment options, including medication-assisted treatment and behavioral therapies, is essential for helping individuals overcome addiction and achieve long-term recovery. policy implications and future directions addressing the complex challenges of socioeconomic barriers to health outcomes among hispanic populations impacted by fentanyl requires a multi-faceted approach involving policy changes, community-level interventions, and individual-level support. policies reducing poverty, improving educational opportunities, and expanding affordable healthcare access are crucial for special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 26 2024, vol. 4 no. s1 pg. 15-29 creating a healthier and more equitable environment [8]. increased provider education on health disparities and cultural competency can improve healthcare service quality and effectiveness for hispanic populations [8]. investing in research to better understand this population’s specific needs and challenges can inform more effective intervention development. future research should evaluate culturally tailored intervention effectiveness, explore social networks and community support’s role in promoting health, and examine policy changes’ impact on health outcomes. collaboration between researchers, healthcare providers, community organizations, and policymakers is essential to develop and implement sustainable solutions addressing health disparities’ root causes and improving hispanic border populations’ lives. this review’s findings highlight the urgent need for comprehensive and collaborative efforts to address the complex interplay of socioeconomic factors, cultural influences, and fentanyl’s devastating impact. by dismantling healthcare access barriers, promoting culturally sensitive interventions, and addressing substance use's root causes, we can strive toward a more equitable and healthier future for hispanic communities along the texas-mexico border. acknowledgements: nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. funding: funded by dhr health high school and community outreach; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. muennig pa, reynolds m, fink ds, zafari z, geronimus at. america’s declining wellbeing, health, and life expectancy: not just a white problem. american journal of public health. 2018;108(12):1626-1631. doi:https://doi.org/10.2105/ajph.2018.304585 2. burkhalter n, walker ss, davis m, flynn a. integrating primary, behavioral and spiritual health care to improve patient outcomes. journal of behavioral health and psychology. 2021;10(4). doi:https://doi.org/10.33425/2832-4579/21033 3. ghaddar s, brown cj, pagán ja, díaz v. acculturation and healthy lifestyle habits among hispanics in united states-mexico border communities. revista panamericana de salud pública. 2010;28(3). doi:https://doi.org/10.1590/s1020-49892010000900009 4. prophete l. barriers to medication adherence in the hispanic population. fpuscholarworks.fresno.edu. published 2018. accessed january 7, 2025. https://www.semanticscholar.org/paper/barriers-to-medication-adherence-in-thehispanic-prophete/da707abb2afa3fdaea4353f1331c777aeaba22b3 5. talavera-garza l, ghaddar s, valerio m, garcia c. health care access and utilization among hispanic manufacturing workers along the texas-mexico border. journal of https://doi.org/10.2105/ajph.2018.304585 https://doi.org/10.33425/2832-4579/21033 https://doi.org/10.1590/s1020-49892010000900009 https://www.semanticscholar.org/paper/barriers-to-medication-adherence-in-the-hispanic-prophete/da707abb2afa3fdaea4353f1331c777aeaba22b3 https://www.semanticscholar.org/paper/barriers-to-medication-adherence-in-the-hispanic-prophete/da707abb2afa3fdaea4353f1331c777aeaba22b3 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 27 2024, vol. 4 no. s1 pg. 15-29 health care for the poor and underserved. 2013;24(2):656-670. doi:https://doi.org/10.1353/hpu.2013.0072 6. bastida e, brown hs, pagán ja. persistent disparities in the use of health care along the us–mexico border: an ecological perspective. american journal of public health. 2008;98(11):1987-1995. doi:https://doi.org/10.2105/ajph.2007.114447 7. diaz fc, osuna-salazar en, robledo c, machiorlatti m, sarhill n, kwang h. trends and variations in female breast cancer along the texas-mexico border trends and variations in breast cancer along the texas-mexico border. cancer research. 2020;80(4_supplement):p6-1104-p611-04. doi:https://doi.org/10.1158/15387445.sabcs19-p6-11-04 8. nesbitt s, palomarez re. review: increasing awareness and education on health disparities for health care providers. ethnicity & disease. 2016;26(2):181-190. doi:https://doi.org/10.18865/ed.26.2.181 9. anderson j, demeter n, pasquires m, wirtz s. using the ca opioid overdose surveillance dashboard to track opioid overdose deaths. online journal of public health informatics. 2019;11(1). doi:https://doi.org/10.5210/ojphi.v11i1.9938 10. vuocolo b, sierra r, brooks d, et al. reducing time to diagnosis of rare genetic diseases in a medically underserved hispanic populationlessons learned for meaningful engagement. research square (research square). published online december 13, 2023. doi:https://doi.org/10.21203/rs.3.rs-3699740/v1 11. mata h, provencio-vasquez e, martinez j, de santis j. hiv risk knowledge among hispanic adults in a u.s. – mexico border community. californian journal of health promotion. 2014;12(1):88-94. doi:https://doi.org/10.32398/cjhp.v12i1.1559 12. geographic disparities in diabetes-related amputations—texas-mexico border, 2003. jama. 2007;297(10):1051. doi:https://doi.org/10.1001/jama.297.10.1051 13. calip gs, hoskins kf, guadamuz js. examining the associations among treatment declination, racial and ethnic inequities, and breast cancer survival. jama network open. 2024;7(5):e249402. doi:https://doi.org/10.1001/jamanetworkopen.2024.9402 14. robles a, bashashati m, contreras a, et al. colorectal cancer in hispanics living near the u.s. mexico border. revista de investigacion clinica. 2019;71(5). doi:https://doi.org/10.24875/ric.19003026 15. li c, mou j. ethnic disparities in the prevalence of sars-cov-2 testing positivity comparing hispanic and non-hispanic populations. big data. published online april 1, 2022:2977-2977. doi:https://doi.org/10.1370/afm.20.s1.2977 16. chow ds, glavis-bloom j, soun je, et al. development and external validation of a prognostic tool for covid-19 critical disease. ashkenazi i, ed. plos one. 2020;15(12):e0242953. doi:https://doi.org/10.1371/journal.pone.0242953 17. ramirez ag, chalela p, rowan s, et al. avanzando caminos (leading pathways): the hispanic/latino cancer survivorship cohort study. cancer epidemiology, biomarkers & prevention. 2023;32(12_supplement):b044-b044. doi:https://doi.org/10.1158/15387755.disp23-b044 18. flores be, guerrero j, bobadilla r, craven ck. hepatitis c virus (hcv) screening and treatment in south texas us-mexico border persistent poverty counties. cancer epidemiology biomarkers & prevention. 2023;32(12_supplement):ia045-ia045. doi:https://doi.org/10.1158/1538-7755.disp23-ia045 https://doi.org/10.1353/hpu.2013.0072 https://doi.org/10.2105/ajph.2007.114447 https://doi.org/10.1158/1538-7445.sabcs19-p6-11-04 https://doi.org/10.1158/1538-7445.sabcs19-p6-11-04 https://doi.org/10.18865/ed.26.2.181 https://doi.org/10.5210/ojphi.v11i1.9938 https://doi.org/10.21203/rs.3.rs-3699740/v1 https://doi.org/10.32398/cjhp.v12i1.1559 https://doi.org/10.1001/jama.297.10.1051 https://doi.org/10.1001/jamanetworkopen.2024.9402 https://doi.org/10.24875/ric.19003026 https://doi.org/10.1370/afm.20.s1.2977 https://doi.org/10.1371/journal.pone.0242953 https://doi.org/10.1158/1538-7755.disp23-b044 https://doi.org/10.1158/1538-7755.disp23-b044 https://doi.org/10.1158/1538-7755.disp23-ia045 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 28 2024, vol. 4 no. s1 pg. 15-29 19. bowman ba, vinicor f. toward prevention and control of type 2 diabetes: challenges at the u.s.-mexico border and beyond 1 | scholars portal journals. scholarsportal.info. published 2025. accessed january 7, 2025. https://journals.scholarsportal.info/details/15451151/v02i0001/nfp_tpacotatubab.xml 20. gareis ce, hunter p, leader a. the impact of the promotoras program on knowledge, attitudes, and cervical cancer screening among hispanic/latina women: rapid review. cancer epidemiology, biomarkers & prevention. 2023;32(1_supplement):b023-b023. doi:https://doi.org/10.1158/1538-7755.disp22-b023 21. shiels ms, berrington de gonzález a, best af, et al. premature mortality from all causes and drug poisonings in the usa according to socioeconomic status and rurality: an analysis of death certificate data by county from 2000–15. the lancet public health. 2019;4(2):e97-e106. doi:https://doi.org/10.1016/s2468-2667(18)30208-1 22. angell sy, cetron ms. health disparities among travelers visiting friends and relatives abroad. annals of internal medicine. 2005;142(1):67. doi:https://doi.org/10.7326/00034819-142-1-200501040-00013 23. fisher-hoch sp, vatcheva kp, rahbar mh, mccormick jb. undiagnosed diabetes and pre-diabetes in health disparities. kirchmair r, ed. plos one. 2015;10(7):e0133135. doi:https://doi.org/10.1371/journal.pone.0133135 24. bencomo-alvarez ae, nhim v, alvarado l, et al. effects of race, ethnicity, and country of origin on incidence and survival in breast cancer. cancer epidemiology, biomarkers & prevention. 2023;32(1_supplement):c066-c066. doi:https://doi.org/10.1158/15387755.disp22-c066 25. bauer c, zhang k, lee m, et al. census tract patterns and contextual social determinants of health associated with covid-19 in a hispanic population from south texas: a spatiotemporal perspective. jmir public health and surveillance. 2021;7(8):e29205. doi:https://doi.org/10.2196/29205 26. spierling sr, savin kl, soriano ec, et al. process evaluation of dulce digital-me: an adaptive mobile health (mhealth) intervention for underserved hispanics with diabetes. translational behavior of medicine. published online april 3, 2023. doi:https://doi.org/10.1093/tbm/ibad020 27. borkowski p, borkowska n, shaunak mangeshkar, adal bh, singh n. racial and socioeconomic determinants of cardiovascular health: a comprehensive review. curēus. published online may 2, 2024. doi:https://doi.org/10.7759/cureus.59497 28. ramirez fg, alvarado l, dwivedi a, chacon j. immunotherapy treatment disparities: a tcr analysis of patients with cutaneous melanoma. cancer epidemiology, biomarkers & prevention. 2023;32(12_supplement):b051-b051. doi:https://doi.org/10.1158/15387755.disp23-b051 29. jones ba, eger w, suttiratana s, et al. abstract s12-06: social determinants of health (sdoh) barriers as predictors of intent to vaccinate for covid-19 in a vulnerable population. clinical cancer research. 2021;27(6_supplement):s12-06s12-06. doi:https://doi.org/10.1158/1557-3265.covid-19-21-s12-06 30. chandhok ns, shrestha a, watts jm, bradley t, sekeres ma. outcomes for hispanic patients with acute leukemia treated at academic centers. blood. 2021;138(supplement 1):2282-2282. doi:https://doi.org/10.1182/blood-2021-151250 https://journals.scholarsportal.info/details/15451151/v02i0001/nfp_tpacotatubab.xml https://doi.org/10.1158/1538-7755.disp22-b023 https://doi.org/10.1016/s2468-2667(18)30208-1 https://doi.org/10.7326/0003-4819-142-1-200501040-00013 https://doi.org/10.7326/0003-4819-142-1-200501040-00013 https://doi.org/10.1371/journal.pone.0133135 https://doi.org/10.1158/1538-7755.disp22-c066 https://doi.org/10.1158/1538-7755.disp22-c066 https://doi.org/10.2196/29205 https://doi.org/10.1093/tbm/ibad020 https://doi.org/10.7759/cureus.59497 https://doi.org/10.1158/1538-7755.disp23-b051 https://doi.org/10.1158/1538-7755.disp23-b051 https://doi.org/10.1158/1557-3265.covid-19-21-s12-06 https://doi.org/10.1182/blood-2021-151250 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.2 dhr proceedings ǀ http://dhrproceedings.org 29 2024, vol. 4 no. s1 pg. 15-29 31. ramirez ag, munoz e, holden aec, adeigbe rt, suarez l. incidence of hepatocellular carcinoma in texas latinos, 1995–2010: an update. mehta as, ed. plos one. 2014;9(6):e99365. doi:https://doi.org/10.1371/journal.pone.0099365 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.4 dhr proceedings ǀ http://dhrproceedings.org 45 2024, vol. 4 no. s1 pg. 45-52 manuscript adolescent added sugar consumption and colon cancer risk in hispanic adults: a public health perspective marisol acosta1, jackylin vela 1,4, klarissa ramos 1,5 , abigail salinas1,3 , sofia flores1,6, zasherry salazar 1,6, mya velasquez 1,7, allyson elizondo 1,2, olivia reyes1,4 1dhr health high school and community outreach 2 south texas preparatory academy 3la joya high school 4 san isidro high school 5 rio hondo isd 6 james nikki rowe high school 7 lasara high school received: july 12, 2024 accepted for publication: january 6, 2025 introduction the rising incidence of colorectal cancer (crc) globally, coupled with concerning trends in early-onset crc, necessitates a comprehensive understanding of its risk factors [1], [2]. dietary habits, particularly during adolescence, are increasingly recognized as playing a significant role in crc development [2]. this literature review examines the current evidence on the association between adolescent added sugar consumption and colon cancer risk in hispanic adults, focusing on the public health implications of this relationship. the review will analyze existing studies, highlighting methodological strengths and weaknesses, identifying research gaps, and synthesizing findings to inform future research and public health interventions. adolescent sugar intake and crc risk: an overview numerous studies have investigated the link between sugar intake and crc risk, but the evidence remains complex and often contradictory [3], [4]. some studies suggest a positive association between high sugar and sugar-sweetened beverage (ssb) consumption during adolescence and an increased risk of colorectal adenomas, precursors to crc [2]. joh et al. [2] found a positive association between high adolescent intake of simple sugars (fructose, glucose, added sugar, total sugar) and ssbs with the risk of conventional adenomas, particularly rectal adenomas. specifically, for every 5% increase in total fructose intake per day, the multivariable odds ratio for total adenoma was 1.17 (95% ci 1.05–1.31), and for high-risk adenoma, it was special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.4 dhr proceedings ǀ http://dhrproceedings.org 46 2024, vol. 4 no. s1 pg. 45-52 1.30 (95% ci 1.06–1.60) [2]. similarly, hur et al. [5] observed a more than doubled risk of early-onset crc (eo-crc) among women consuming two servings of ssbs per day compared to those consuming less than one serving per week in adulthood. furthermore, each additional serving per day of ssb intake during adolescence (ages 13-18) was associated with a 32% higher risk of eo-crc [5]. however, other studies have failed to demonstrate a clear association between overall sugar intake and crc risk [3], [6]. in a large-scale japanese cohort study, kanehara et al. [3] found no significant association between various types of sugar intake and crc risk in middle-aged adults. while a positive association was observed between total sugar consumption and rectal cancer in women, this was not statistically significant in men [3]. similarly, cho et al. [6] found no association between high sugar intake and the prevalence of colorectal adenomas in the japanese population. these conflicting findings underscore the need for further research to clarify the complex relationship between sugar intake and crc risk, considering factors such as ethnicity, age, and other lifestyle factors. methodological considerations and research gaps the studies reviewed employed various methodologies, including prospective cohort studies [2], [3], [5], [7], case-control studies [8], [9], and cross-sectional studies [6]. prospective cohort studies offer a more substantial design for assessing temporal relationships between exposure and outcome, but they are expensive and time-consuming and may suffer from attrition bias [2]. case-control studies are more efficient but susceptible to recall and selection bias [8]. crosssectional studies provide a snapshot of the association at a single point in time, limiting the ability to infer causality [6]. several methodological limitations exist across the studies: dietary assessment: most studies relied on self-reported nutritional data through food frequency questionnaires (ffqs) [2], [3], [5], [6], which are subject to measurement error and recall bias. dietary recall accuracy can vary depending on factors like age, education, and cultural background [10]. confounding factors: many studies adjusted for potential confounding factors such as age, sex, bmi, smoking, physical activity, and alcohol consumption [2], [3], [5]. however, residual confounding may still exist, affecting the observed associations [11]. subgroup analyses: while some studies conducted subgroup analyses by sex, age, or bmi [2], [3], [5], further stratification by ethnicity, particularly within hispanic populations, is crucial to understanding potential variations in risk [12]. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.4 dhr proceedings ǀ http://dhrproceedings.org 47 2024, vol. 4 no. s1 pg. 45-52 specific sugar types: studies often examine total sugar intake or a limited number of particular sugar types [2], [3]. a more detailed assessment of different kinds of added sugars and their contributions to crc risk is needed [13]. longitudinal studies: long-term follow-up is essential to establish the long-term effects of adolescent sugar consumption on crc risk in adulthood [2]. many studies lack the extended follow-up periods necessary to fully capture the development of crc [11]. hispanic populations: a significant gap exists in the literature regarding the specific impact of adolescent sugar consumption on crc risk within diverse hispanic populations [14], [15]. the limited number of studies focusing on hispanic populations hinders the ability to draw definitive conclusions about this subgroup [12]. further research is needed to address the distinct dietary patterns and cultural influences within different hispanic subgroups [14]. biological mechanisms and pathways the potential biological mechanisms linking high sugar intake, particularly during adolescence, to increased crc risk remain to be fully elucidated [16], [17]. however, several plausible pathways have been proposed: inflammation: high sugar intake can promote chronic inflammation, a known risk factor for crc [16]. stewart et al. [16] found associations between sugar intake and certain inflammationrelated biomarkers in crc patients, although the findings were influenced by adiposity. oxidative stress: excess sugar can induce oxidative stress, damaging cellular components and potentially contributing to cancer development [17]. lombello et al. [17] highlight the role of oxidative stress as a mechanism linking processed and ultra-processed foods, often high in added sugars, to crc. gut microbiota dysbiosis: high sugar intake can disrupt the gut microbiota, altering its composition and function [17], [18]. an imbalance in gut microbiota, known as dysbiosis, has been linked to increased crc risk [17]. herchenhorn and tarouquella [18] discuss the potential link between nut consumption, which may modify the gut microbiota, and reduced colon cancer recurrence. insulin resistance and hyperinsulinemia: high sugar intake can lead to insulin resistance and hyperinsulinemia, which have been implicated in crc development [6], [19]. increased insulin levels may promote cell growth and proliferation, contributing to tumorigenesis [19]. advanced glycation end products (ages): high-sugar diets and high-temperature cooking processes can lead to the formation of ages in foods [20]. ages are implicated in promoting inflammation and oxidative stress, potentially contributing to cancer development [20]. panguluri and findlay [20] highlight the potential link between dietary ages and breast cancer risk, suggesting the need for further research into their role in other cancers. special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.4 dhr proceedings ǀ http://dhrproceedings.org 48 2024, vol. 4 no. s1 pg. 45-52 public health implications and interventions the potential implications of adolescent sugar consumption on crc risk in hispanic adults are significant from a public health perspective [21], [22]. given the rising prevalence of obesity and chronic diseases associated with high sugar intake, particularly within hispanic communities, targeted interventions are crucial [23], [24]. these interventions should consider the following: dietary guidelines and education: public awareness of the potential link between adolescent sugar consumption and crc risk is essential [25]. educational campaigns targeting adolescents and their families, emphasizing the importance of limiting added sugar intake and adopting healthier dietary patterns, are vital [26], [27]. the effectiveness of these interventions should be assessed across different hispanic subgroups [12]. policy interventions: policy interventions, such as sugar-sweetened beverage taxes and regulations on marketing to children, have been proposed to reduce ssb consumption [21], [22], [28]. the cost-effectiveness of such interventions should be carefully evaluated, considering the potential impact on health outcomes and economic burden [21], [22], [29]. lee et al. [21] explored the health and economic impacts of various ssb tax policies in the united states. shangguan et al. [22] modeled the potential effects of voluntary sugar reduction targets in the us. alcaraz et al. [29] estimated the disease burden attributable to ssb consumption in four latin american and caribbean countries. technology-based interventions: technology-based interventions, such as smartphone apps and online tools, may help monitor sugar intake and provide personalized feedback [30]. these interventions can be adapted to different cultural contexts and integrated into existing health promotion programs [30]. multi-sectoral approaches: effective interventions require a multi-sectoral approach involving collaboration among government agencies, healthcare professionals, the food industry, educators, and community organizations [31]. this collaborative effort is necessary to address the complex interplay of factors contributing to high sugar intake and crc risk [31]. addressing health disparities: interventions should focus on reducing health disparities within hispanic populations, considering socio-economic factors, cultural beliefs, and access to healthcare [23], [24], [22]. xu et al. [23], [24] highlight the need to consider racial and socioeconomic disparities in cancer-related behaviors among adolescents and parents. conclusion the existing literature on the association between adolescent added sugar consumption and colon cancer risk in hispanic adults is complex and presents conflicting findings. while some studies suggest a positive association, others have not found a clear link. methodological limitations, including reliance on self-reported dietary data, potential confounding factors, and limited special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.4 dhr proceedings ǀ http://dhrproceedings.org 49 2024, vol. 4 no. s1 pg. 45-52 research on hispanic populations, contribute to this uncertainty. further research is crucial to address these limitations and clarify the complex interplay between adolescent sugar intake, biological mechanisms, and crc risk within diverse hispanic subgroups. public health interventions should consider multi-sectoral approaches, including dietary guidelines, policy interventions, technology-based strategies, and culturally tailored programs, to reduce sugar consumption and mitigate the risks of crc within hispanic communities. a strong focus on addressing health disparities and promoting healthy lifestyles throughout adolescence is paramount for reducing the burden of crc. future research should prioritize longitudinal studies with large, diverse samples and detailed dietary assessments, incorporating genetic and other biomarkers to understand the underlying mechanisms better and develop effective prevention strategies [32]. including more varied hispanic populations in future studies is crucial to providing culturally relevant and effective interventions [12]. the role of specific types of added sugars, the impact of dietary patterns, and the interaction with other risk factors also require further investigation [13], [17], [11]. understanding the interplay between dietary factors, gut microbiota, and inflammation in crc development within hispanic populations is a significant area for future research [16], [17], [18]. finally, evaluating the long-term impact of adolescent dietary habits on adult health outcomes, including crc risk, is essential for developing effective public health strategies [2], [5]. acknowledgements: nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. funding: funded by dhr health high school and community outreach; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.4 dhr proceedings ǀ http://dhrproceedings.org 50 2024, vol. 4 no. s1 pg. 45-52 bibliography 1. wang l, du m, wang k, et al. association of ultra-processed food consumption with colorectal cancer risk among men and women: results from three prospective us cohort studies. bmj. 2022;378:e068921. doi:https://doi.org/10.1136/bmj-2021-068921 2. joh hk, lee dh, hur j, et al. simple sugar and sugar-sweetened beverage intake during adolescence and risk of colorectal cancer precursors. gastroenterology. published online march 2021. doi:https://doi.org/10.1053/j.gastro.2021.03.028 3. rieko kanehara, katagiri r, goto a, et al. sugar intake and colorectal cancer risk: a prospective japanese cohort study. cancer science. 2023;114(6):2584-2595. doi:https://doi.org/10.1111/cas.15766 4. burley vj. sugar consumption and cancers of the digestive tract. european journal of cancer prevention. 1997;6(5):422-434. doi:https://doi.org/10.1097/00008469199710000-00003 5. hur j, otegbeye e, joh hk, et al. sugar-sweetened beverage intake in adulthood and adolescence and risk of early-onset colorectal cancer among women. gut. published online march 30, 2021. doi:https://doi.org/10.1136/gutjnl-2020-323450 6. cho h, budhathoki s, kanehara r, et al. association between dietary sugar intake and colorectal adenoma among cancer screening examinees in japan. cancer science. 2020;111(10):3862-3872. doi:https://doi.org/10.1111/cas.14596 7. zhang x, albanes d, beeson wl, et al. risk of colon cancer and coffee, tea, and sugar-sweetened soft drink intake: pooled analysis of prospective cohort studies. jnci journal of the national cancer institute. 2010;102(11):771-783. doi:https://doi.org/10.1093/jnci/djq107 8. kim y, lee j, oh jh, et al. the association between coffee consumption and risk of colorectal cancer in a korean population. nutrients. 2021;13(8):2753. doi:https://doi.org/10.3390/nu13082753 9. tuyns aj, kaaks r, haelterman m. colorectal cancer and the consumption of foods: a case‐control study in belgium. nutrition and cancer. 1988;11(3):189-204. doi:https://doi.org/10.1080/01635588809513986 10. brantley kd, hartman tj, patel av, gapstur sm, flanders w, mccullough ml. testretest reproducibility of adult-reported high school diet varies among racially and ethnically diverse us men and women. the journal of nutrition. 2018;148(4):599-606. doi:https://doi.org/10.1093/jn/nxy001 11. papier k, bradbury ke, balkwill a, et al. diet-wide analyses for risk of colorectal cancer: prospective study of 12,250 incident cases among 543,000 women in the uk. medrxiv (cold spring harbor laboratory). published online june 13, 2024. doi:https://doi.org/10.1101/2024.06.12.24308822 12. palacios c, daniel cr, tirado-gómez m, et al. abstract b14: dietary patterns in puerto rican and mexican-american breast cancer survivors: a pilot study. cancer https://doi.org/10.1136/bmj-2021-068921 https://doi.org/10.1053/j.gastro.2021.03.028 https://doi.org/10.1111/cas.15766 https://doi.org/10.1097/00008469-199710000-00003 https://doi.org/10.1097/00008469-199710000-00003 https://doi.org/10.1136/gutjnl-2020-323450 https://doi.org/10.1093/jnci/djq107 https://doi.org/10.3390/nu13082753 https://doi.org/10.1080/01635588809513986 https://doi.org/10.1093/jn/nxy001 https://doi.org/10.1101/2024.06.12.24308822 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.4 dhr proceedings ǀ http://dhrproceedings.org 51 2024, vol. 4 no. s1 pg. 45-52 epidemiology, biomarkers & prevention. 2015;24(10_supplement):b14-b14. doi:https://doi.org/10.1158/1538-7755.disp14-b14 13. huang y, chen z, chen b, et al. dietary sugar consumption and health: umbrella review. bmj. 2023;381:e071609. doi:https://doi.org/10.1136/bmj-2022-071609 14. julyann perez-mayoral, julian s, marievelisse soto-salgado, gonzalez mj, cruz-correa m. abstract 240: dietary patterns and risk of colorectal neoplasia in puerto rican hispanics: a case control study. cancer research. 2017;77(13_supplement):240-240. doi:https://doi.org/10.1158/1538-7445.am2017-240 15. mack tm, walker a, mack w, bernstein l. cancer in hispanics in los angeles county. national cancer institute monograph. 1985;69:99-104. https://pubmed.ncbi.nlm.nih.gov/3834353/ 16. stewart kl, gigic b, himbert c, et al. association of sugar intake with inflammation and angiogenesis-related biomarkers in newly diagnosed colorectal cancer patients. nutrition and cancer. 2021;74(5):1636-1643. doi:https://doi.org/10.1080/01635581.2021.1957133 17. maroco s, dutra im, valério i, frederico a, cibele velloso-rodrigues. impact of processed and ultra-processed foods on colorectal cancer risk: mechanisms, dietary factors, and protective compound. research society and development. 2024;13(7):e14813746446-e14813746446. doi:https://doi.org/10.33448/rsd-v13i7.46446 18. herchenhorn d, tarouquella j. diet intervention and colon cancer recurrence: nut consumption or microbiota manipulation? cancer reports and reviews. 2018;3(1). doi:https://doi.org/10.15761/crr.1000178 19. fadelu t, niedzwiecki d, zhang s, et al. nut consumption and survival in stage iii colon cancer patients: results from calgb 89803 (alliance). journal of clinical oncology. 2017;35(15_suppl):3517-3517. doi:https://doi.org/10.1200/jco.2017.35.15_suppl.3517 20. panguluri ga, findlay vj. rising breast cancer rates in younger women: could dietary advanced glycation end products be the missing link? journal of young women’s breast cancer and health. 2024;1(1&2):13-19. doi:https://doi.org/10.4103/ywbc.ywbc_11_24 21. lee y, mozaffarian d, sy s, et al. health impact and cost-effectiveness of volume, tiered, and absolute sugar content sugar-sweetened beverage tax policies in the united states. circulation. 2020;142(6):523-534. doi:https://doi.org/10.1161/circulationaha.119.042956 22. shangguan s, mozaffarian d, sy s, et al. health impact and cost-effectiveness of achieving the national salt and sugar reduction initiative voluntary sugar reduction targets in the united states: a micro-simulation study. circulation. 2021;144(17). doi:https://doi.org/10.1161/circulationaha.121.053678 https://doi.org/10.1158/1538-7755.disp14-b14 https://doi.org/10.1136/bmj-2022-071609 https://doi.org/10.1158/1538-7445.am2017-240 https://pubmed.ncbi.nlm.nih.gov/3834353/ https://doi.org/10.1080/01635581.2021.1957133 https://doi.org/10.33448/rsd-v13i7.46446 https://doi.org/10.15761/crr.1000178 https://doi.org/10.1200/jco.2017.35.15_suppl.3517 https://doi.org/10.4103/ywbc.ywbc_11_24 https://doi.org/10.1161/circulationaha.119.042956 https://doi.org/10.1161/circulationaha.121.053678 special edition: advanced clinical research internship session ii (2024), vol. 4 no. s1 https://doi.org/10.47488/dhrp.v4is1.4 dhr proceedings ǀ http://dhrproceedings.org 52 2024, vol. 4 no. s1 pg. 45-52 23. xu l, odum m, williams rd, housman jm. the flashe study: racial and sex disparities in adolescent and parent modifiable cancer risk behavior. american journal of health behavior. 2019;43(5):912-923. doi:https://doi.org/10.5993/ajhb.43.5.4 24. xu l, odum m, rogers cr, wu q, wilmouth l. association between family/neighborhood cancer risk factors and adolescent dietary behaviors: a parentadolescent dyadic analysis. american journal of lifestyle medicine. published online august 21, 2020:155982762094921. doi:https://doi.org/10.1177/1559827620949215 25. alessa m, alarfaj mo, albenayyan ha, et al. awareness of the link between the consumption of ultra-processed food and colorectal cancer risk in saudi arabia. cureus journal of medical science. 2023;15(1). doi:https://doi.org/10.7759/cureus.33774 26. tang q, lin q, yang q, sun m, liu h, yang l. knowledge, attitude, and practice of adolescent parents on free sugar and influencing factors about recognition. international journal of environmental research and public health. 2020;17(11):4003. doi:https://doi.org/10.3390/ijerph17114003 27. park s, lee sh, merlo c, blanck hm. associations between knowledge of health risks and sugar-sweetened beverage intake among us adolescents. nutrients. 2023;15(10):2408. doi:https://doi.org/10.3390/nu15102408 28. costa d, warkentin s, oliveira a. sugar-sweetened beverages, effects on appetite and public health strategies to reduce the consumption among children: a review. porto biomedical journal. 2022;7(1):e172. doi:https://doi.org/10.1097/j.pbj.0000000000000172 29. alcaraz a, bardach ae, espinola n, et al. health and economic burden of disease of sugar-sweetened beverage consumption in four latin american and caribbean countries: a modelling study. bmj open. 2023;13(2):e062809. doi:https://doi.org/10.1136/bmjopen-2022-062809 30. ezike c, da silva k. technology-based interventions to reduce sugar-sweetened beverages among adolescents: a scoping review. international journal of environmental research and public health. 2023;20(23):7101. doi:https://doi.org/10.3390/ijerph20237101 31. ayala gx, monge‐rojas r, king ac, hunter r, berge jm. entorno social y obesidad infantil: implicaciones para la investigación y la práctica en estados unidos y en los países latinoamericanos. obesity reviews. 2021;22(s5). doi:https://doi.org/10.1111/obr.13350 32. stern mc, joel sanchez mendez, kim ae, et al. genome-wide gene–environment interaction analyses to understand the relationship between red meat and processed meat intake and colorectal cancer risk. cancer epidemiology, biomarkers & prevention. 2024;33(3):of1-of11. doi:https://doi.org/10.1158/1055-9965.epi-23-0717 https://doi.org/10.5993/ajhb.43.5.4 https://doi.org/10.1177/1559827620949215 https://doi.org/10.7759/cureus.33774 https://doi.org/10.3390/ijerph17114003 https://doi.org/10.3390/nu15102408 https://doi.org/10.1097/j.pbj.0000000000000172 https://doi.org/10.1136/bmjopen-2022-062809 https://doi.org/10.3390/ijerph20237101 https://doi.org/10.1111/obr.13350 https://doi.org/10.1158/1055-9965.epi-23-0717 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.3 dhr proceedings ǀ http://dhrproceedings.org 15 2024, vol. 4 no. s2 pg. 15-23 manuscript adverse effects of red 40 in pepsico products on neurodevelopmental health in low-income hispanic communities near the texas-mexico border marisol acosta1, alinna liyana loa1,2, ximena garcia1,3, mia nicole garcia1,2, melissa medina1,2, shaeer ahmad1,2, catalina peña1,3, and alexandra ocañas1,3 1 dhr health high school and community outreach 2 south texas isd health professions 3 south texas isd medical professions received: july 3, 2024 accepted for publication: january 24, 2025 introduction this literature review examines the potential adverse effects of red 40, a synthetic food color widely used in pepsico products, on neurodevelopmental health within low-income hispanic communities residing near the texas-mexico border. the review focuses on the intersection of food consumption patterns, environmental exposures, and health disparities within this vulnerable population. while direct research linking red 40 consumption in pepsico products to neurodevelopmental issues in this specific demographic is limited, this review synthesizes existing research on red 40's potential effects, the dietary habits of the target population, and the broader context of health inequalities along the us-mexico border. red 40 and potential neurodevelopmental effects several studies have raised concerns about the potential adverse effects of red 40 (allura red ac) on behavior and neurodevelopment, primarily in children.1 dietary exposure to red 40 in children, based on data from the 2015-2016 national health and nutrition examination survey (nhanes), frequently exceeded acceptable daily intakes (adis) established by the fda and who. this suggests a potential for widespread exposure, particularly among children, who consume high levels of red 40 through juice drinks, soft drinks, icings, and ice cream cones.1 however, the study did not directly assess neurodevelopmental outcomes, only focusing on the extent of exposure.1 further research is needed to establish a clear causal link between red 40 exposure and specific neurodevelopmental problems.1 additional research using comprehensive approaches, such as those employed in zebrafish embryo studies examining the effects of various smoke dyes including red 9 (similar chemical structure to red 40), could offer valuable insights into potential mechanisms of toxicity.2 perkins et al. found that disperse red 9 impaired special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.3 dhr proceedings ǀ http://dhrproceedings.org 16 2024, vol. 4 no. s2 pg. 15-23 behavior at all concentrations tested in zebrafish embryos, suggesting potential neurotoxicity.2 however, extrapolating these findings to humans requires caution due to species differences in metabolism and response to chemicals.2 dietary habits and food insecurity in border colonias low-income hispanic communities along the us-mexico border, often referred to as "colonias," face significant challenges related to food access and nutrition.3 the high rates of poverty, food insecurity, and obesity within these communities. limited access to affordable, healthy foods, coupled with the pervasive marketing of less healthy options, contributes to poor dietary habits.34 the prevalence of ultra-processed foods (upfs), which often contain high levels of added sugars, fats, and artificial additives like red 40, is a significant concern.5-6 the link between upf consumption and obesity, a factor known to increase the risk of several neurodevelopmental problems.5 the global spread of upfs and their potential to compromise health at various levels, including cognitive and mental health.6 the high consumption of sugar-sweetened beverages, often containing red 40, is another factor contributing to poor dietary quality in these communities.7-8 the lack of clear front-of-package labeling regarding added sugar content, making it difficult for consumers to make informed choices.7 the association between nss soft drink consumption (which may or may not contain red 40) and lower socioeconomic status in greek children, suggesting a similar pattern could exist in the studied communities.8 stein and chakraborty further demonstrate the disproportionate presence of fast-food outlets near neighborhoods with larger proportions of racial/ethnic minorities, even after accounting for socioeconomic factors.4 this unequal access to healthy food options exacerbates existing health disparities. health disparities and neurodevelopmental outcomes the confluence of factors with limited access to healthy food, high consumption of upfs containing red 40, and existing socioeconomic inequalities create a complex interplay that can negatively impact neurodevelopmental outcomes in low-income hispanic communities near the texas-mexico border.9-10 the hispanic health paradox, where hispanics in the us have longer lifespans despite facing numerous health disparities, including higher rates of food insecurity.9 however, this paradox doesn't negate the significant health challenges faced by this population, including potential neurodevelopmental risks related to diet and environmental factors.9 the additional disadvantages faced by hispanic and latino cancer survivors, which includes limited access to equitable treatment options and sociodemographic adversities.10 these inequalities are frequently rooted in disparate social determinants of health, including limited access to healthy and affordable food and barriers to community health/exercise opportunities.10 while not directly related to red 40, this emphasizes the broader context of health inequities that may exacerbate the impact of dietary exposures on neurodevelopmental outcomes.10 furthermore, the impact of air pollution, another prevalent environmental risk factor in these areas, on children's mental health needs further investigation.11 finnding in the associations between air pollution exposure and behavioral/developmental disorders, anxiety, and eating disorders in rural children, highlighting the importance of considering multiple environmental stressors.11 the potential cumulative effect of these factors, including dietary exposures to red 40, on neurodevelopment requires further study. special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.3 dhr proceedings ǀ http://dhrproceedings.org 17 2024, vol. 4 no. s2 pg. 15-23 research gaps and future directions this review highlights significant research gaps regarding the specific impact of red 40 in pepsico products on neurodevelopmental health in low-income hispanic communities along the texas-mexico border. further research is needed to: establish a direct causal link: studies are needed to directly assess the relationship between red 40 consumption (specifically from pepsico products) and neurodevelopmental outcomes within this specific population. this requires well-designed epidemiological studies with appropriate control groups and adjustments for confounding factors such as socioeconomic status, overall diet quality, and other environmental exposures. investigate potential mechanisms: research is needed to understand the potential biological mechanisms through which red 40 might affect neurodevelopment. this could involve examining its effects on gut microbiota, immune function, and brain development at a cellular level.12-13 the gut-brain axis and the influence of diet on neurodevelopment, suggest a potential avenue for investigation.12 the interplay between diet, microbiota, and brain processes, suggest that whole-dietary approaches should be considered.13 consider cumulative effects: future research should consider the cumulative effects of multiple risk factors, including red 40 exposure, food insecurity, and environmental pollutants, on neurodevelopmental outcomes. this requires a holistic approach that integrates data on multiple exposures and health outcomes. address methodological limitations: many existing studies on red 40 and neurodevelopment have limitations in terms of study design, sample size, and assessment of neurodevelopmental outcomes. future studies should employ robust methodologies to minimize bias and increase the generalizability of findings. engage communities: research involving border communities should prioritize community engagement and culturally sensitive approaches. this includes working closely with community members to design studies, recruit participants, and disseminate findings. the success of the "eat healthy, be active" workshops in empowering mexican american women demonstrates the importance of culturally appropriate interventions with positive changes in healthy eating practices among participants.14 conclusion while the evidence linking red 40 to neurodevelopmental problems remains inconclusive, particularly within low-income hispanic communities near the texas-mexico border, existing research raises significant concerns. the high prevalence of food insecurity, limited access to nutritious food, and widespread consumption of ultra-processed foods (upfs), including those containing red 40, contribute to an environment that may pose risks to neurodevelopmental health. addressing these challenges requires further research using rigorous methodologies and a holistic approach that considers multiple interacting factors. special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.3 dhr proceedings ǀ http://dhrproceedings.org 18 2024, vol. 4 no. s2 pg. 15-23 this review highlights the critical need for comprehensive investigations into the health impacts of food additives and packaging materials, including potential interactions that may influence human health. studies on artificial food coloring and hyperactivity, though controversial, underscore the importance of continued exploration into the long-term consequences of dietary exposures, particularly in vulnerable populations. additionally, emerging evidence suggests that maternal covid-19 infection during pregnancy, even without vertical transmission, could have long-term implications for fetal development and neurodevelopmental outcomes, including potential cognitive and behavioral issues such as adhd. the complex interplay of genetic and environmental factors, exemplified by the sexbiasing influence of ube3a gene overdosage, further emphasizes the multifaceted nature of neurodevelopmental disorders. beyond red 40, the broader context of socioeconomic disparities including food insecurity and environmental exposures which remains a crucial determinant of health outcomes. addressing these disparities through improved access to healthy food and targeted public health interventions is essential to promoting better neurodevelopmental health in these communities. evidence from related health concerns, such as chronic kidney disease and cardiometabolic diseases, reinforces the need to consider social determinants of health in designing effective interventions. furthermore, lessons from agricultural systems in teaching kitchens suggest that collaborative, community-based approaches can address diet-related chronic diseases and improve food systems. policy-driven solutions informed by u.s. food policy initiatives offer potential strategies to enhance dietary quality and reduce health disparities. insights from international studies on toxic trace elements in food highlight the importance of monitoring environmental contaminants and their potential health impacts. the review also points to the potential of bio-based packaging materials and natural food preservatives as sustainable solutions to reduce exposure to harmful chemicals. advances in dietary interventions, such as targeted probiotic delivery, highlight the promise of emerging technologies in enhancing public health outcomes. finally, addressing health disparities requires a comprehensive approach that includes educational interventions, behavioral modifications, and policy reforms. programs focusing on nutrition, such as school-based family asthma educational initiatives and dietary interventions for adhd management, provide valuable models for future efforts. understanding the relationships between diet, environmental exposures, and health outcomes will be crucial in shaping effective, evidence-based strategies to mitigate risks and promote well-being in underserved communities. in conclusion, tackling the complex interplay of food additives, environmental exposures, and social determinants of health requires a multidisciplinary approach. future research should prioritize the unique needs of low-income hispanic populations and develop culturally tailored interventions that address both immediate dietary concerns and broader systemic inequities. special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.3 dhr proceedings ǀ http://dhrproceedings.org 19 2024, vol. 4 no. s2 pg. 15-23 acknowledgements: nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. funding: funded by dhr health high school and community outreach; dhr health; south texas independent school district. references 1. bradman a, castorina r, thilakaratne r, et al. dietary exposure to united states food and drug administration-approved synthetic food colors in children, pregnant women, and women of childbearing age living in the united states. international journal of environmental research and public health. 2022;19(15):9661. doi:https://doi.org/10.3390/ijerph19159661 2. perkins ej, to kt, lindsey st. mary, et al. developmental, behavioral and transcriptomic changes in zebrafish embryos after smoke dye exposure. toxics. 2022;10(5):210-210. doi:https://doi.org/10.3390/toxics10050210 3. sharkey j, meyer ru, st. john j. promotora‐academic partnership to reduce nutritional health disparities among mexican‐heritage families in texas border colonias. the faseb journal. 2016;30(s1). doi:https://doi.org/10.1096/fasebj.30.1_supplement.901.11 4. stein do, chakraborty j. racial, ethnic, and socioeconomic disparities in exposure to fast food in hillsborough county, florida. florida public health review. 2010;7(1):83-92. 5. monda a, ida m, villano i, et al. ultra-processed food intake and increased risk of obesity: a narrative review. foods. 2024;13(16):2627-2627. doi:https://doi.org/10.3390/foods13162627 6. prescott sl, d’adamo cr, holton kf, ortiz s, overby n, logan ac. beyond plants: the ultra-processing of global diets is harming the health of people, places, and planet. international journal of environmental research and public health. 2023;20(15):6461. doi:https://doi.org/10.3390/ijerph20156461 7. marks ab. taming america’s sugar rush: a traffic-light label approach. ssrn electronic journal. 2020;62(683). doi:https://doi.org/10.2139/ssrn.3731112 https://doi.org/10.3390/ijerph19159661 https://doi.org/10.3390/toxics10050210 https://doi.org/10.1096/fasebj.30.1_supplement.901.11 https://doi.org/10.3390/foods13162627 https://doi.org/10.3390/ijerph20156461 https://doi.org/10.2139/ssrn.3731112 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.3 dhr proceedings ǀ http://dhrproceedings.org 20 2024, vol. 4 no. s2 pg. 15-23 8. apergi k, malisova o, vlassopoulos a, fidanoglou p, kandyliari a, kapsokefalou m. investigating the sociodemographic and health characteristics of non-sugar sweeteners consumption in greek school-aged children: a cross-sectional study. children. 2024;11(7):813. doi:https://doi.org/10.3390/children11070813 9. hem-lee-forsyth s, sandoval b, bryant h. a tridimensional view of the hispanic health paradox: its relationship with faith, the enclave theory, and familism. advances in social sciences research journal. 2021;8(12):317-345. doi:https://doi.org/10.14738/assrj.812.11476 10. kronenfeld jp, graves kd, penedo fj, yanez b. overcoming disparities in cancer: a need for meaningful reform for hispanic and latino cancer survivors. the oncologist. 2021;26(6):443-452. doi:https://doi.org/10.1002/onco.13729 11. mota-bertran a, coenders g, plaja p, saez m, barceló ma. air pollution and children’s mental health in rural areas: compositional spatio-temporal model. scientific reports. 2024;14(1):1-13. doi:https://doi.org/10.1038/s41598-024-70024-2 12. larroya a, pantoja j, codoñer-franch p, cenit mc. towards tailored gut microbiome-based and dietary interventions for promoting the development and maintenance of a healthy brain. frontiers in pediatrics. 2021;9. doi:https://doi.org/10.3389/fped.2021.705859 13. berding k, vlckova k, marx w, et al. diet and the microbiota–gut–brain axis: sowing the seeds of good mental health. advances in nutrition. 2021;12(4). doi:https://doi.org/10.1093/advances/nmaa181 14. briant kj, sanchez j, galvan a, gonzalez v, wu-georges s, thompson b. abstract a35: eat healthy, be active community workshops for a rural hispanic population. cancer epidemiology biomarkers & prevention. 2017;26(2_supplement):a35-a35. doi:https://doi.org/10.1158/1538-7755.disp16-a35 15. andreea ioana enache (bontos, marius daniel bontos, danut ionel vaireanu. a novel information system for studying the interactions between, foods, food additives and packaging materials. revista de chimie. 2013;64(10):1139-1142. https://www.researchgate.net/publication/262609981_a_novel_information_system _for_studying_the_interactions_between_foods_food_additives_and_packaging_m aterials 16. wheaton ag. short sleep duration among infants, children, and adolescents aged 4 months–17 years — united states, 2016–2018. mmwr morbidity and mortality weekly report. 2021;70(38). doi:https://doi.org/10.15585/mmwr.mm7038a1 https://doi.org/10.3390/children11070813 https://doi.org/10.14738/assrj.812.11476 https://doi.org/10.1002/onco.13729 https://doi.org/10.1038/s41598-024-70024-2 https://doi.org/10.3389/fped.2021.705859 https://doi.org/10.1093/advances/nmaa181 https://doi.org/10.1158/1538-7755.disp16-a35 https://www.researchgate.net/publication/262609981_a_novel_information_system_for_studying_the_interactions_between_foods_food_additives_and_packaging_materials https://www.researchgate.net/publication/262609981_a_novel_information_system_for_studying_the_interactions_between_foods_food_additives_and_packaging_materials https://www.researchgate.net/publication/262609981_a_novel_information_system_for_studying_the_interactions_between_foods_food_additives_and_packaging_materials https://doi.org/10.15585/mmwr.mm7038a1 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.3 dhr proceedings ǀ http://dhrproceedings.org 21 2024, vol. 4 no. s2 pg. 15-23 17. zimmermann lk. chronotype and the transition to college life. chronobiology international. 2011;28(10):904-910. doi:https://doi.org/10.3109/07420528.2011.618959 18. mark lawrence wong, nagata jm, barreto m. sleep and socioemotional outcomes among sexual and gender minority adolescents: a longitudinal study. archives of sexual behavior. published online november 22, 2023. doi:https://doi.org/10.1007/s10508-023-02732-1 19. keuppens l, marten f, dieter baeyens, boyer b, danckaerts m, van. sleep intervention as symptom treatment for adhd (siesta)-blended cbt sleep intervention to improve sleep, adhd symptoms and related problems in adolescents with adhd: protocol for a randomised controlled trial. bmj open. 2023;13(4):e065355-e065355. doi:https://doi.org/10.1136/bmjopen-2022-065355 20. kim j, vander stoep a, mccauley e. 0394 differential role of sleep problems on depression and suicide in community adolescents. sleep. 2020;43(supplement_1):a151-a151. doi:https://doi.org/10.1093/sleep/zsaa056.391 21. shen c, mireku mo, martina di simplicio, et al. bidirectional associations between sleep problems and behavioural difficulties and health‐related quality of life in adolescents: evidence from the scamp longitudinal cohort study. jcpp advances. 2022;2(3). doi:https://doi.org/10.1002/jcv2.12098 22. shen c, smith rb, heller j, et al. depression and anxiety in adolescents during the covid-19 pandemic in relation to the use of digital technologies: longitudinal cohort study. journal of medical internet research. 2024;26(1):e45114. doi:https://doi.org/10.2196/45114 23. mcmakin dl, alfano ca. sleep and anxiety in late childhood and early adolescence. current opinion in psychiatry. 2015;28(6):483-489. doi:https://doi.org/10.1097/yco.0000000000000204 24. thapa s, yadav dk. role of sleep problem on suicidal behaviour and non-suicidal self-injury among adolescents in pokhara, nepal. islam mds, ed. plos one. 2024;19(9):e0305221. doi:https://doi.org/10.1371/journal.pone.0305221 25. chang ly, chang hy, lin ln, wu cc, yen ll. transitions in sleep problems from late adolescence to young adulthood: a longitudinal analysis of the effects of peer victimization. aggressive behavior. 2017;44(1):69-82. doi:https://doi.org/10.1002/ab.21725 https://doi.org/10.3109/07420528.2011.618959 https://doi.org/10.1007/s10508-023-02732-1 https://doi.org/10.1136/bmjopen-2022-065355%5c https://doi.org/10.1093/sleep/zsaa056.391 https://doi.org/10.1002/jcv2.12098 https://doi.org/10.2196/45114 https://doi.org/10.1097/yco.0000000000000204 https://doi.org/10.1371/journal.pone.0305221 https://doi.org/10.1002/ab.21725 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.3 dhr proceedings ǀ http://dhrproceedings.org 22 2024, vol. 4 no. s2 pg. 15-23 26. wolfson ar, harkins e, johnson m, marco c. effects of the young adolescent sleep smart program on sleep hygiene practices, sleep health efficacy, and behavioral well-being. sleep health. 2015;1(3):197-204. doi:https://doi.org/10.1016/j.sleh.2015.07.002 27. gupta m, gupta n, fradkin y, petti t. sleep disturbances in children and adolescents with autism spectrum disorder: an overview for clinicians. adolescent psychiatry. 2023;13. doi:https://doi.org/10.2174/2210676613666230126115646 28. morales-muñoz i, durdurak bb, bilgin a, marwaha s, winsper c. understanding the relationship between sleep problems in early childhood and borderline personality disorder: a narrative review. nature and science of sleep. 2021;volume 13:21752202. doi:https://doi.org/10.2147/nss.s311672 29. chattu v, manzar md, kumary s, burman d, spence d, pandi-perumal s. the global problem of insufficient sleep and its serious public health implications. healthcare. 2018;7(1):1. doi:https://doi.org/10.3390/healthcare7010001 30. brenda, morrissey a, wu y, et al. pica practices, anemia, and oral health outcomes: a systemic review. bmc oral health. 2025;25(1). doi:https://doi.org/10.1186/s12903-024-05371-7 31. mbou asm, djoko grp, ketchaji a, et al. determinants of anemia in school-going adolescents: a case study in douala, cameroon. bmc public health. 2025;25(1). doi:https://doi.org/10.1186/s12889-024-21224-y 32. pinto s, correia-de-sá t, sampaio-maia b, vasconcelos c, moreira p, ferreira-gomes j. eating patterns and dietary interventions in adhd: a narrative review. nutrients. 2022;14(20):4332. doi:https://doi.org/10.3390/nu14204332 33. holscher hd, chumpitazi bp, dahl wj, et al. perspective: assessing tolerance to nondigestible carbohydrate consumption. advances in nutrition. published online august 30, 2022. doi:https://doi.org/10.1093/advances/nmac091 34. capra me, monopoli d, stanyevic b, et al. plant-based diets in pediatric subjects: heart-healthy option or dangerous choice? healthcare. 2024;12(22):2290. doi:https://doi.org/10.3390/healthcare12222290 35. bold kw, kong g, o’malley ss. the scientific basis for the regulation of flavors in tobacco products. annual review of clinical psychology. 2024;20(1). doi:https://doi.org/10.1146/annurev-clinpsy-080921-075624 https://doi.org/10.1016/j.sleh.2015.07.002 https://doi.org/10.2174/2210676613666230126115646 https://doi.org/10.2147/nss.s311672 https://doi.org/10.3390/healthcare7010001 https://doi.org/10.1186/s12903-024-05371-7 https://doi.org/10.1186/s12889-024-21224-y https://doi.org/10.3390/nu14204332 https://doi.org/10.1093/advances/nmac091 https://doi.org/10.3390/healthcare12222290 https://doi.org/10.1146/annurev-clinpsy-080921-075624 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.3 dhr proceedings ǀ http://dhrproceedings.org 23 2024, vol. 4 no. s2 pg. 15-23 36. le pn, adachi y, anastasiou e, et al. global change, climate change, and asthma in children: direct and indirect effects a wao pediatric asthma committee report. world allergy organization journal. 2024;17(11):100988-100988. doi:https://doi.org/10.1016/j.waojou.2024.100988 37. luo ys, chen z, blanchette ad, et al. relationships between constituents of energy drinks and beating parameters in human induced pluripotent stem cell (ipsc)derived cardiomyocytes. food and chemical toxicology. 2021;149:111979. doi:https://doi.org/10.1016/j.fct.2021.111979 38. rahelić v, perković t, romić l, et al. the role of behavioral factors on chronic diseases—practice and knowledge gaps. healthcare. 2024;12(24):2520. doi:https://doi.org/10.3390/healthcare12242520 39. baker bh, melough mm, paquette ag, et al. ultra-processed and fast food consumption, exposure to phthalates during pregnancy, and socioeconomic disparities in phthalate exposures. environment international. 2024;183:108427. doi:https://doi.org/10.1016/j.envint.2024.108427 40. trumbo pr, bleiweiss-sande r, campbell jk, et al. toward a science-based classification of processed foods to support meaningful research and effective health policies. frontiers in nutrition. 2024;11. doi:https://doi.org/10.3389/fnut.2024.1389601 https://doi.org/10.1016/j.waojou.2024.100988 https://doi.org/10.1016/j.fct.2021.111979 https://doi.org/10.3390/healthcare12242520 https://doi.org/10.1016/j.envint.2024.108427 https://doi.org/10.3389/fnut.2024.1389601 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.101 dhr proceedings ǀ http://dhrproceedings.org 98 2023, vol. 2 no. s2 98-104 commentary primary hereditary microcephaly: a review yudith antonio1, ernesto lozano1, nicole m. garcia2, gisela j. izaguirre2, abner n. juarez2, ruben m. pena3, jasmine n. garza3, elodia ann de los santos3, krystin garza3, lilliana d. cano3, rose sanchez4 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 martin high school, laredo, tx 3 cigarroa high school, laredo, tx 4 benavides high school, benavides, tx 5 zapata high school, zapata, tx received: november 2, 2023 accepted for publication: november 3, 2023 published : november 16, 2023 introduction microcephaly primary hereditary or mcph, is a neurological and genetic disorder that is characterized by a reduced head circumference, growth delay, and intellectual disability.1 microcephaly is categorized by primary and secondary microcephaly.2 primary is congenital, which means that the genetic disorder is present before birth and secondary is postnatal, meaning that it appears after birth or later on in life. microcephaly is caused by a frameshift mutation, via insertion or deletion, and this mutation occurs in at least seven genes. there are a number of factors that may cause microcephaly. microcephaly may be hereditary, with both parents being carriers of the genetic mutation and mutations causing an alteration of proteins; however, environmental factors, such as viral infections and toxins, may also play a role in the appearance of genetic mutations.2 there are less than 5,000 people in the united states affected by microcephaly.1 the rate of microcephaly in newborns in the united states is 8.7 in every 10,000 births, which is very low, revealing how rare microcephaly is.2 the most obvious sign of microcephaly in newborns is the small and underdeveloped size of the cerebrum in the brain . this makes it possible for microcephaly to be diagnosed and become noticeable while the child is still developing inside the mother via ultrasound. other forms of diagnosis include blood testing and amniocentesis. this genetic disorder is lifelong but can be treated based on the severity of the disease in a person affected. a variety of therapy techniques used for treating primary microcephaly include physical therapy, speech, alternative therapy, and a holistic therapy approach. the treatments being performed on the patients is directly proportional to their prognosis. the development of those affected by microcephaly can vary especially when considering their cognitive and social development. etiology to better comprehend the etiology of mcph, it must first be understood that mcph is an inherited disorder that affects the autosomal chromosomes, pairs 1-22.3 mcph is caused by a frameshift mutation or nucleotide deletion.4 an individual who inherits this disorder must receive a copy of the diseased gene from each of their parents. this mutation occurs in at least seven genes: aspm, cdk5rap, cenpj, cep152, knl1, stil, and wdr62.5 these microcephaly associated genes are highly involved in cell-cycle related processes such as centriole biogenesis, mitotic spindle organization, cell cycle checkpoint or chromosome segregation. the aspm gene or abnormal spindle-like microcephaly-associated gene is located on chromosome 1.4 it is responsible for encoding proteins that are involved in bodily functions and processes. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.101 dhr proceedings ǀ http://dhrproceedings.org 99 2023, vol. 2 no. s2 98-104 specifically speaking, the aspm gene encodes proteins that are densely involved in brain development and the production of neural progenitor cells.4 neural progenitor cells are nerve cells found in the central nervous system. they are responsible for restoring damage in the brain as well as interacting with microglia cells. an abnormality in this gene can result in microcephaly primary autosomal recessive or mcph.5 the cdk5rap gene or regulatory subunit associated with protein 2, is a gene located in chromosome 9. the cdk5rap gene allows the initiation of the cell cycle by encoding a regulator of cdk5 (cyclin-dependent kinase 5) activity.6 this occurs in phase g1 of the cell cycle where cyclins combine with cyclin-dependent kinase for gene transcription and gene translation. additionally, cdk5rap is also activated during the mitotic spindle checkpoint. before proceeding towards anaphase, the cdk5rap gene ensures that the duplicated chromosomes are properly attached to the spindle microtubules of each kinetochore. mutations in this gene are linked to primary microcephaly.6 the cenpj or centromere protein j, is a gene located in chromosome 13.7 it maintains centrosome activity and begins microtubule disassembly during anaphase, the separation of sister chromatids. cep152 or centrosomal protein 152, is a gene located in chromosome 15. similar to cenpj, cep152 also aids in centrosome function. mutations in these genes are associated with primary microcephaly.8 the knl1 or kinetochore scaffold 1 is a gene located in chromosome 15. knl1 serves as a scaffold protein for kinetochore-microtubule attachment and chromosome segregation.9 a scaffold protein binds with multiple proteins to relay messages between other cells at a faster rate. its binding nature allows it to ensure that the chromosomes are correctly aligned and attached before the sister chromatids are pulled apart by the spindle microtubules (reference). alterations in the gene are directly correlated with primary microcephaly and the formation of tumors.9 stil centriolar assembly protein located in chromosome 1 is responsible for regulating the mitotic spindle checkpoint through the process of chromosome distribution.10 although a mutation in this gene is associated with mcph, more research has to be conducted for a better understanding. wdr62 or wd repeat domain 62 is a gene located in chromosome 19. wdr62 or wd repeat domain 62 is a gene located in chromosome 19. wdr62 plays a role in the growth and development of the brain.11 a mutation in this gene can result in delayed psychomotor development. risk factors genetic: protein alteration an alteration of proteins is a related risk factor within primary microcephaly. the ctnnb1 gene is responsible for producing a protein called bcatenin 1. this protein has a hand in connecting cadherins and the actin cytoskeleton in adherent junctions.12 it has a vital function in preserving the integrity of epithelial layers and supporting adhesion, communication, and signaling between nearby cells. the wnt signaling pathway, discovered in metazoan animals, is remarkably conserved. the term ‘wnt’ originated from the fusion of ‘wingless’.” drosophila segment polarity, a gene responsible for segment polarity in drosophila, and “integrated” or ‘int-1,’ its vertebrate counterpart.12 extracellular wnt signal triggers various intracellular signaling cascades, such as the canonical (wnt b catenin dependent) pathway and the non-canonical (b cateninindependent) pathway, which includes the planar cell polarity pathway and the wnt/ca2+ pathway.12.wnt proteins are crucial regulators in a diverse array of cellular processes, including cell fate determination, motility, polarity, primary axis formation, and organ development. furthermore, recent research has revealed their involvement in stem cell renewal within the biologic pathway, which is essential for the development of embryos and the maintenance of tissue balance in adulthood.12 recent studies have indicated that mutations resulting in the loss of ctnnb1 function during embryonic stages are linked to cognitive disabilities.12 furthermore, various syndromic phenotypic characteristics, including microcephaly, have been observed and reported in case studies and series.12 this alteration of the ctnnb1 gene must be present within both parents for a child to be affected and develop primary microcephaly. viral infection: zika virus (zikv) notably, microcephaly has been linked to various infectious agents such as toxoplasma gondii, cytomegalovirus, rubella virus, syphilis, herpes simplex virus, hiv, and zika virus in infants at birth. the extent of microcephaly is determined not only by the particular infectious agent but also significantly by the gestational age when the infection takes place.2 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.101 dhr proceedings ǀ http://dhrproceedings.org 100 2023, vol. 2 no. s2 98-104 research has revealed that these pathogens primarily target neural progenitors.2 however, the precise mechanisms through which most of these infections lead to microcephaly remain incompletely understood. nevertheless, a thorough investigation in this area was sparked by the high association between the zika virus and its connection to congenital microcephaly. numerous studies using both in vitro and in vivo animal models have shown that zika virus infection causes npc cell cycle arrest or increased cell mortality. interestingly, research data shows that the expression of several genes linked to microcephaly, including mcph1, aspm, centrosomal protein, and stil, is reduced in brain tissues removed from zikainfected mice.2 it indicates that the microcephaly brought on by infection may have an effect on brain development by altering the expression of different mcph genes. nevertheless, it is important to acknowledge the direct role that infectious agents play in the emergence of microcephaly.2 signs and symptoms: primary microcephaly autosomal recessive primary microcephaly is a neurological and genetic disorder that occurs congenitally. the most common indicator of microcephaly is the presence of an undeveloped cerebrum. usually, symptoms start presenting themselves antepartum, which is why it can be diagnosed during pregnancy. it is vital to remember that signs are dictated by the severity and categorization of the disability.1 oftentimes, symptoms include poor appetite, which leads to unhealthy weight gain or weight loss. this causes deficient growth among the children. they also struggle with balance and movement. due to joint deformities and a lack of motor skills, these kids are not able to perform tasks such as running, walking, and sitting. seizures are very common amongst children with microcephaly as well. they develop issues such as speech delays, learning disabilities, sociability delays, and intellectual delays.24 their brain does not function in the way a healthy child's brain would, which is why they struggle when socializing with other kids, learning, or trying to make decisions. lastly, they also have complications with their vision and hearing, causing them to struggle seeing things or listening. as previously stated, a small head and brain is the most common sign of microcephaly. dwarfism is not as common but is also on the list. this is when a person has shorter stature than what would be considered typical. a sloping forehead is usual in children with microcephaly. a lot of these children also have facial deformities, which are deformities that affect the bones and face. joint deformities are also very similar and are also recurrent in children with mcph. these joint deformities contribute to the struggle they have when it comes to simple motor skills. the bones do not develop as they should and affect their abilities.13 diagnosis microcephaly can be diagnosed from approximately 18 to 22 weeks of gestation and after delivery. ultrasound and mri testing are the primary ways to find microcephaly in newborns and fetuses.14 ultrasounds are the primary source to access fetal growth during pregnancies. finding microcephaly after birth, the provider will measure the head circumference, then the provider will compare it to a standard female or male. microcephaly is diagnosed when the infant’s head circumference is more than 2 standard deviations below the average.15 liquid biopsies microcephaly can also be found through blood samples. the tests can be run in the early stages of pregnancy to see if the fetus has the condition. from the blood samples, the doctors can also run genetic tests to see if there is any mutation in the genes of the baby or if the condition runs in the family.16 amniocentesis an amniocentesis test can be run between 1518 weeks of pregnancy. a small sample of amniotic fluid collected from the area surrounding the baby is collected to test for any zika genetic material.17 the test is recommended until after the 15th week to reduce complications that could happen if the test is done before that time.18 treatment physical therapy microcephaly is an extremely expansive disorder, each case is unique. nevertheless, cases could have similar symptoms. physical therapy is essential and can help a patient's condition greatly by boosting their sense of wellbeing and, ideally, restoring their ability to walk. this article discussed various physical therapy treatments to treat microcephaly caused by the zika virus.19 trunk rotation techniques are the main source of therapy and are truly a game changer in a patient’s lives. please give a short explanation of trunk rotation techniques here. this treatment could be applied to primary special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.101 dhr proceedings ǀ http://dhrproceedings.org 101 2023, vol. 2 no. s2 98-104 microcephaly exhibiting comparable symptoms.19 children who suffer from this condition can gain from specific exercises and programs that will improve their motor and developmental skills.20 trunk rotation techniques affect motor function, interact with other physical components and neurological systems in a mutually dependent manner, and are crucial for limb movements.20 lacking trunk rotation processes have a number of negative effects, including a lack of trunk stability, increased muscle tone in the upper and lower limbs, a delay or loss of the postural reaction, and weakness in the trunk muscles.20 the main objective is to make your back muscles more flexible while also increasing the back's ability to rotate. physical therapy is truly an important intervention in patients with microcephaly. speech therapy speech therapy helps individuals expand or gain a way to communicate. individuals with microcephaly are prone to have speech delays and overall developmental delays.21 accordingly, speech therapy is recommended and a standard way to help people with microcephaly navigate their life on account of no known treatment.22 not all individuals with microcephaly are able to communicate verbally. the use of other means of communication is implemented through the use of nonverbal communication. individuals may also use sign language to communicate. by using and learning sign language individuals possess the information to be able to express themselves. alternative therapies alternative therapies provide several benefits and do not typically follow a traditional route, such as support groups in this instance fall under alternative therapies. these groups contain a common factor where they discuss a specific topic and members help structure their day to day lives. an advantage of joining a support group essentially supplies assistance, community, and support to children and their families.23 if local community support groups aren’t available , online support groups provide options for individuals with mcph. online support groups tend to cater to a variety of people with different backgrounds and their respective different experiences. prognosis children affected by this condition may experience symptoms such as hindered development, intellectual disability, and mobility issues.27 depending on the severity of microcephaly, the prognosis of the condition can prove fatal. head size does not always necessarily tie to prognosis.13 symptoms will prove different for each case. patients that improve do so with close monitoring and assistance through therapy, nutritional monitoring, and other supportive interventions. the physical therapies can help with their strength and maneuverability. nutritional monitoring aids in rebuilding strength and energy levels, therefore helping microcephaly patients with growth. prognosis for each patient differs depending on resources provided and severity of mcph.13 lifelong development life expectancy in autosomal recessive primary microcephaly a patient’s life expectancy significantly differs from person to person depending on the severity of their condition and several other factors that come into play within their diagnosis. furthermore, not every case of primary microcephaly is entirely similar, in some occasions with the right care a patient with primary microcephaly can go on to have an ordinary life expectancy. genetics greatly determines the expected lifetime of a patient because of the underlying conditions and complex mutations in the family’s medical history, often unbeknownst to them.15 additionally, the symptoms vary significantly from patient to patient while at times being accompanied by a variety of developmental conditions and physical disabilities that impede basic capabilities. consequently, the greater the gravity of this disease the higher the risk of impact to brain function is increased with the possibility of hindering lifespan.24. while the occurrence of microcephaly in offspring is a rather rare possibility, having the resources to provide the necessities and care a patient requires, leads to positive influences towards their life expectancy. cognitive development primary microcephaly will be present in a patient’s brain throughout their entire lifetime. in a cognitive sense, this means that their conscious intellectual activity is impaired and the afflicted individuals will face difficulties in performing tasks that those unaffected deem as basic functions. the capacity for critical thinking is altered in a patient with primary microcephaly.5 their lack of understanding of complex objectives and inept proficiency to use logic special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.101 dhr proceedings ǀ http://dhrproceedings.org 102 2023, vol. 2 no. s2 98-104 sets them back from those around them. as a crucial skill for the intake of knowledge, memory execution and retainment are especially central to the cognitive development of the brain. this can be specifically troublesome during the academic years of young patients under the arduous demands of a school environment or lack thereof causing them to fall behind their peers. moreover, in a physical aspect the mind’s control over motor skills is inefficient meaning that the essential skills used in movement such as coordination and balance are limited, in turn affecting their participation in physical activities or simple tasks in daily life.25 social development in a social environment, basic communication and interaction skills are used, but it can be strenuous for a patient with this neurodevelopmental disorder to operate as a member of society. expression requires the right structure of words, social cues, and emotions.21 being able to exchange sentences in a clear and concise manner while using listening skills with the appropriate expressions to respond effectively to someone adds to the stress of having this condition making patients feel the need to be isolated from social environments due to their difficulties.26 these barriers to socialization emphasize the need for inclusiveness and support from those around them. conclusion microcephaly primary hereditary otherwise known as mcph is a genetic and hereditary condition caused by a frameshift mutation and is defined as a head more than two standard deviations below normal head circumference. the most common cause of mcph is a mutation in the aspm gene due to it encoding proteins involved in brain development.4 this explains why brain development is affected. the severity of primary microcephaly determines the range of symptoms experienced by the afflicted. symptoms vary from physical abnormalities deviating from what is typically seen on healthy individuals, to slowed development. treatment plans are individualized for each patient and require constant monitoring and support in order to achieve the most positive prognosis. life expectancy correlates to the severity of the patient’s microcephaly, taking into consideration that microcephalic patients may have other comorbidities. while this condition may affect physical, cognitive, and social development, severe cases demonstrate failure to thrive. acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. autosomal recessive primary microcephaly | genetic and rare diseases information center (gard) – an ncats program. nih.gov. published 2015. https://rarediseases.info.nih.gov/diseases/12 117/autosomal-recessive-primarymicrocephaly 2. zaqout s, kaindl am. autosomal recessive primary microcephaly: not just a small brain. front cell dev biol. 2022;9:784700. published 2022 jan 17. doi:10.3389/fcell.2021.784700 3. cleveland clinic. autosomal dominant & autosomal recessive inheritance & disorders. cleveland clinic. published may 21, 2022. https://my.clevelandclinic.org/health/body/2 3078-autosomal-dominant--autosomalrecessive 4. medlineplus, national library of medicine (nih). aspm gene: medlineplus genetics. medlineplus.gov. published april 1, 2011. https://medlineplus.gov/genetics/gene/aspm/ 5. medlineplus, national library of medicine (nih). autosomal recessive primary microcephaly: medlineplus genetics. medlineplus.gov. published april 1, 2011. https://medlineplus.gov/genetics/condition/a utosomal-recessive-primarymicrocephaly/#frequency 6. national library of medicine (nih). cdk5rap2 cdk5 regulatory subunit associated protein 2 [homo sapiens (human)] gene ncbi. www.ncbi.nlm.nih.gov. published july 18, 2023. https://www.ncbi.nlm.nih.gov/gene/55755?_ https://rarediseases.info.nih.gov/diseases/12117/autosomal-recessive-primary-microcephaly https://rarediseases.info.nih.gov/diseases/12117/autosomal-recessive-primary-microcephaly https://rarediseases.info.nih.gov/diseases/12117/autosomal-recessive-primary-microcephaly https://my.clevelandclinic.org/health/body/23078-autosomal-dominant--autosomal-recessive https://my.clevelandclinic.org/health/body/23078-autosomal-dominant--autosomal-recessive https://my.clevelandclinic.org/health/body/23078-autosomal-dominant--autosomal-recessive https://medlineplus.gov/genetics/gene/aspm/ https://medlineplus.gov/genetics/condition/autosomal-recessive-primary-microcephaly/#frequency https://medlineplus.gov/genetics/condition/autosomal-recessive-primary-microcephaly/#frequency https://medlineplus.gov/genetics/condition/autosomal-recessive-primary-microcephaly/#frequency https://www.ncbi.nlm.nih.gov/gene/55755?_%0cga=2.224898834.906660625.1689557476-928239188.1689286280 special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.101 dhr proceedings ǀ http://dhrproceedings.org 103 2023, vol. 2 no. s2 98-104 ga=2.224898834.906660625.1689557476928239188.1689286280 7. national library of medicine. cenpj centromere protein j [homo sapiens (human)] gene ncbi. www.ncbi.nlm.nih.gov. published june 21, 2023. https://www.ncbi.nlm.nih.gov/gene/55835?_ ga=2.13599351.1520561885.1689739575928239188.1689286280 8. national library of medicine (nih). cep152 centrosomal protein 152 [homo sapiens (human)] gene ncbi. www.ncbi.nlm.nih.gov. published june 21, 2023. https://www.ncbi.nlm.nih.gov/gene/22995?_ ga=2.13020151.1520561885.1689739575928239188.1689286280 9. national library of medicine (nih). knl1 kinetochore scaffold 1 [homo sapiens (human)] gene ncbi. www.ncbi.nlm.nih.gov. published july 9, 2023. https://www.ncbi.nlm.nih.gov/gene/57082?_ ga=2.28946356.906660625.1689557476928239188.1689286280 10. national library of medicine (nih). stil stil centriolar assembly protein [homo sapiens (human)] gene ncbi. www.ncbi.nlm.nih.gov. published june 21, 2023. https://www.ncbi.nlm.nih.gov/gene/6491?_g a=2.55920235.1520561885.1689739575928239188.1689286280 11. national library of medicine (nih). wdr62 wd repeat domain 62 [homo sapiens (human)] gene ncbi. www.ncbi.nlm.nih.gov. published july 18, 2023. https://www.ncbi.nlm.nih.gov/gene/284403? _ga=2.80497239.1520561885.1689739575928239188.1689286280 12. komiya y, habas r. wnt signal transduction pathways. organogenesis. 2008;4(2):68-75. doi:10.4161/org.4.2.5851 13. boston children's hospital. microcephaly | boston children’s hospital. www.childrens hospital.org. published 2023. https://www.childrenshospital.org/condition s/microcephaly#:~:text=the%20main%20fe ature%20of%20microcephaly 14. okafor c, kanekar s. imaging of microcephaly . clinicalkeycom. 2022;49(3):693-713. https://www.clinicalkey.com/# 15. cdc. facts about microcephaly. centers for disease control and prevention. published december 7, 2016. https://www.cdc.gov/ncbddd/birthdefects/mi crocephaly.html 16. stanford medicine children's health. stanford children’s health. stanfordchildrens.org. https://www.stanfordchildrens.org/en/topic/d efault?id=microcephaly-90-p02610 17. centers for disease control and prevention (cdc). cs305590-a what to know if your doctor suspects microcephaly during pregnancy.; 2021. https://www.cdc.gov/pregnancy/zika/family/ documents/whattoknow-doctor-suspectsmicrocephaly.pdf 18. centers for disease control and prevention (cdc). prenatal care | zika and pregnancy | cdc. centers for disease control and prevention. published april 20, 2020. https://www.cdc.gov/pregnancy/zika/testingfollow-up/prenatal-care.html 19. shin jw, song gb, ko j. the effects of neck and trunk stabilization exercises on cerebral palsy children's static and dynamic trunk balance: case series. j phys ther sci. 2017;29(4):771-774. doi:10.1589/jpts.29.771 20. dyer a, janove m, roberts h. physical therapy implications of zika and microcephaly in latin america.; 2018:41. https://soundideas.pugetsound.edu/cgi/viewc ontent.cgi?article=1046&context=ptsymposi um 21. verloes a, drunat s, passemard s. aspm primary microcephaly. 2020 apr 2. in: adam mp, mirzaa gm, pagon ra, et al., editors. genereviews® [internet]. seattle (wa): university of washington, seattle; 1993-2023. available from: https://www.ncbi.nlm.nih.gov/books/nbk5 55474/ 22. mayo clinic. microcephaly symptoms and causes. mayo clinic. published 2018. https://www.mayoclinic.org/diseasesconditions/microcephaly/symptomscauses/syc-20375051 23. nord. microcephaly support group national organization for rare disorders. rarediseases.org. published august 11, 2022. https://rarediseases.org/non-memberpatient/microcephaly-support-group/ 24. cleveland clinic. microcephaly: causes, diagnosis, treatment & outcome. cleveland https://www.ncbi.nlm.nih.gov/gene/55755?_%0cga=2.224898834.906660625.1689557476-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/55755?_%0cga=2.224898834.906660625.1689557476-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/55835?_ga=2.13599351.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/55835?_ga=2.13599351.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/55835?_ga=2.13599351.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/22995?_ga=2.13020151.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/22995?_ga=2.13020151.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/22995?_ga=2.13020151.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/57082?_ga=2.28946356.906660625.1689557476-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/57082?_ga=2.28946356.906660625.1689557476-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/57082?_ga=2.28946356.906660625.1689557476-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/6491?_ga=2.55920235.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/6491?_ga=2.55920235.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/6491?_ga=2.55920235.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/284403?_ga=2.80497239.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/284403?_ga=2.80497239.1520561885.1689739575-928239188.1689286280 https://www.ncbi.nlm.nih.gov/gene/284403?_ga=2.80497239.1520561885.1689739575-928239188.1689286280 https://www.childrenshospital.org/conditions/microcephaly#:~:text=the%20main%20feature%20of%20microcephaly https://www.childrenshospital.org/conditions/microcephaly#:~:text=the%20main%20feature%20of%20microcephaly https://www.childrenshospital.org/conditions/microcephaly#:~:text=the%20main%20feature%20of%20microcephaly https://www.clinicalkey.com/ https://www.cdc.gov/ncbddd/birthdefects/microcephaly.html https://www.cdc.gov/ncbddd/birthdefects/microcephaly.html https://www.stanfordchildrens.org/en/topic/default?id=microcephaly-90-p02610 https://www.stanfordchildrens.org/en/topic/default?id=microcephaly-90-p02610 https://www.cdc.gov/pregnancy/zika/family/documents/whattoknow-doctor-suspects-microcephaly.pdf https://www.cdc.gov/pregnancy/zika/family/documents/whattoknow-doctor-suspects-microcephaly.pdf https://www.cdc.gov/pregnancy/zika/family/documents/whattoknow-doctor-suspects-microcephaly.pdf https://www.cdc.gov/pregnancy/zika/testing-follow-up/prenatal-care.html https://www.cdc.gov/pregnancy/zika/testing-follow-up/prenatal-care.html https://soundideas.pugetsound.edu/cgi/viewcontent.cgi?article=1046&context=ptsymposium https://soundideas.pugetsound.edu/cgi/viewcontent.cgi?article=1046&context=ptsymposium https://soundideas.pugetsound.edu/cgi/viewcontent.cgi?article=1046&context=ptsymposium https://www.ncbi.nlm.nih.gov/books/nbk555474/ https://www.ncbi.nlm.nih.gov/books/nbk555474/ https://www.mayoclinic.org/diseases-conditions/microcephaly/symptoms-causes/syc-20375051 https://www.mayoclinic.org/diseases-conditions/microcephaly/symptoms-causes/syc-20375051 https://www.mayoclinic.org/diseases-conditions/microcephaly/symptoms-causes/syc-20375051 https://rarediseases.org/non-member-patient/microcephaly-support-group/ https://rarediseases.org/non-member-patient/microcephaly-support-group/ special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.101 dhr proceedings ǀ http://dhrproceedings.org 104 2023, vol. 2 no. s2 98-104 clinic. published april 17, 2023. https://my.clevelandclinic.org/health/disease s/9843-microcephaly 25. nyc . microcephaly. www.nyc.gov. https://www.nyc.gov/site/doh/health/healthtopics/microcephaly.page 26. ur medicine golisano children's hospital. microcephaly developmental and behavioral pediatrics golisano children’s hospital university of rochester medical center. www.urmc.rochester.edu. published 2023. https://www.urmc.rochester.edu/childrenshospital/developmentaldisabilities/conditions/microcephaly.aspx#:~ :text=birth%20(congenital). 27. hanzlik e, gigante j. microcephaly. children. 2017; 4(6):47. https://doi.org/10.3390/children4060047 https://my.clevelandclinic.org/health/diseases/9843-microcephaly https://my.clevelandclinic.org/health/diseases/9843-microcephaly https://www.nyc.gov/site/doh/health/health-topics/microcephaly.page https://www.nyc.gov/site/doh/health/health-topics/microcephaly.page https://www.urmc.rochester.edu/childrens-hospital/developmental-disabilities/conditions/microcephaly.aspx#:~:text=birth%20(congenital).https://www.urmc.rochester.edu/childrens-hospital/developmental-disabilities/conditions/microcephaly.aspx#:~:text=birth%20(congenital).https://www.urmc.rochester.edu/childrens-hospital/developmental-disabilities/conditions/microcephaly.aspx#:~:text=birth%20(congenital).https://www.urmc.rochester.edu/childrens-hospital/developmental-disabilities/conditions/microcephaly.aspx#:~:text=birth%20(congenital).https://doi.org/10.3390/children4060047 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.7 dhr proceedings ǀ http://dhrproceedings.org 55 2024, vol. 4 no. s1 pg. 55-63 manuscript neurodevelopmental consequences of alcohol abuse in hispanic adolescents (ages 13-19) in the rio grande valley: a review of cognitive and structural brain impacts marisol acosta1, jessica p. carvajal1,3, natalia del castillo1,3, valeria i. garcia1,2,kaitlyn r. lewis1,2, hannah n. navarro1,2, dominic r. policarpio1,2, kai r. saenz1,2 1dhr health high school and community outreach 2 south texas isd health professions 3 south texas isd medical professions received: june 21, 2024 accepted for publication: february 5, 2025 introduction this literature review examines the neurodevelopmental consequences of alcohol abuse in hispanic adolescents (ages 13-19) residing in the rio grande valley. the review focuses on the cognitive and structural brain impacts of alcohol abuse within this specific demographic and geographic context. while research on alcohol's effects on the developing brain is extensive, studies specifically targeting hispanic adolescents in the rio grande valley are limited. this review synthesizes existing literature to identify key findings, research gaps, and areas needing further investigation. the unique cultural and socioeconomic factors within the rio grande valley will be considered where relevant data allows. alcohol use patterns in hispanic adolescents of the rio grande valley understanding the prevalence and patterns of alcohol abuse among hispanic adolescents in the rio grande valley is crucial for contextualizing the neurodevelopmental consequences. while precise data specific to this demographic and region may be scarce, broader studies on hispanic populations and border communities offer valuable insights. research indicates that acculturation significantly influences alcohol use patterns among hispanics.4 men identifying as "very mexican" or "bicultural" exhibit higher risks of alcohol abuse and dependence compared to their "very anglo" counterparts.4 conversely, women show increased heavy episodic drinking as they acculturate, potentially reflecting shifting social norms surrounding alcohol consumption for females in u.s. society.4 this suggests a non-linear relationship between acculturation and special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.7 dhr proceedings ǀ http://dhrproceedings.org 56 2024, vol. 4 no. s1 pg. 55-62 alcohol-related disorders, varying by gender and potentially influenced by unique social dynamics prevalent in border regions like the rio grande valley.4 the study by courtney and polich highlights the epidemiological rise of binge drinking among college-age men and its cognitive implications, which may extend to adolescent populations, underscoring the need for further research on this specific demographic in the rio grande valley.5 furthermore, research on problem drinking among adolescents (ages 15-19) indicates an average of 5 drinks per occasion and consumption on 38% of days during a monitoring week.6 this pattern of binge drinking is concerning given its association with serious alcohol-related problems, particularly its impact on frontal lobe functions and working memory.5,7 cognitive impacts of alcohol abuse alcohol abuse significantly impacts cognitive function, particularly during adolescence, a critical period of brain development.1-3 the prefrontal cortex, hippocampus, and cerebellum are especially vulnerable to alcohol's damaging effects, impacting executive functions, memory, and motor control.1,2 studies using neuropsychological assessments have demonstrated cognitive deficits in adolescents with alcohol use disorders, including impairments in executive functions, which are crucial for planning, decision-making, and inhibitory control.2 the study by crespi et al. utilized joint independent component analysis (jica) on gray and white matter features to reveal widespread structural changes in brain networks involved in executive functioning, salience, and the default-mode network in individuals with alcohol use disorder (aud).2 these neurostructural changes correlated significantly with executive performance, highlighting the link between brain damage and cognitive impairment [2].2 furthermore, research indicates that binge drinking is associated with anomalies in brain functioning, particularly affecting brain oscillations linked to motor inhibition and execution.7 binge drinkers demonstrated lower oscillatory responses in delta and theta frequency ranges during motor tasks, suggesting underlying neural dysfunction without significant differences in event-related potentials.7 the bidirectional relationship between inhibitory control and alcohol use is also noteworthy .8 impaired inhibitory control can predispose individuals to alcohol misuse, while alcohol consumption further impairs inhibitory control, creating a vicious cycle.8 deficits in inhibitory control during adolescence may even predict future alcohol use disorders, highlighting the importance of early intervention.8 a population-based study linked alcohol and cannabis misuse to impaired cognitive abilities in adolescents, including deficits in recall memory, perceptual reasoning, inhibition, and working memory.9 the study suggested that these effects could be due to common underlying vulnerabilities, neuroplasticity, neurotoxicity, or developmental sensitivity, underscoring the complexity of the relationship between substance use and cognitive impairment.9 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.7 dhr proceedings ǀ http://dhrproceedings.org 57 2024, vol. 4 no. s1 pg. 55-62 structural brain impacts of alcohol abuse neuroimaging studies reveal significant structural brain changes associated with alcohol abuse, particularly in adolescents.2,10-11 magnetic resonance imaging (mri) studies have documented alterations in both gray and white matter volumes indicating significant structural damage during critical developmental periods.2,10 specific brain regions, such as the prefrontal cortex, hippocampus, and cerebellum, show greater vulnerability to alcohol's neurotoxic effects.1,10 moreover, studies using mri have demonstrated disrupted cortical volume changes in individuals with prenatal alcohol exposure, suggesting that alcohol's effects on brain structure can begin even before birth.12 in adolescents, alcohol exposure leads to decreased plasticity and increased loss of cortical structure, highlighting the long-term consequences of alcohol abuse on brain development.12 research using mendelian randomization suggests a causal relationship between heavy alcohol use and reductions in subcortical brain volumes, specifically impacting the amygdala and hippocampus.11 these subcortical structures play vital roles in emotional regulation and memory, suggesting that alcohol-induced damage in these areas can have significant long-term consequences on mental health and cognitive function.11 the study by durazzo et al. found that individuals with alcohol use disorder (aud) exhibited significant morphological abnormalities in brain regions, particularly the frontal lobe, before treatment.13 relapsers after treatment demonstrated greater bilateral frontal gray matter volume deficits compared to those who maintained abstinence, suggesting that persistent frontal gray matter volume deficits may serve as an endophenotype for relapse susceptibility.13 the study by de santis et al., comparing men with aud and rats with excessive alcohol consumption, found comparable dti alterations, particularly in the corpus callosum and fornix/fimbria, suggesting an underlying process that evolves soon after cessation of alcohol use.14 these findings highlight the widespread and persistent effects of alcohol abuse on brain structure. neurochemical changes and mechanisms alcohol's impact on the developing brain involves complex neurochemical changes.1 alcohol exposure disrupts normal brain development processes, including alterations in gene expression regulation and molecules involved in cell-cell interactions.1 it interferes with the mitogenic and growth factor response, enhances free radical formation, and deranges glial cell functions.1 in both adult and adolescent brains, alcohol damages specific brain areas through mechanisms involving excitotoxicity, free radical formation, and neuroinflammatory damage resulting from the activation of the innate immune system mediated by tlr4 receptors.1 alcohol also acts on specific membrane proteins, such as neurotransmitter receptors (e.g., nmda, gaba-a), ion channels (e.g., l-type ca2+ channels, girks), and signaling pathways (e.g., pka and pkc signaling).1 these effects contribute to the wide variety of behavioral effects induced by ethanol drinking.1 neuroadaptive changes affecting neurotransmission systems, particularly those sensitive to alcohol's acute effects, occur after long-term alcohol consumption.1 alcohol-induced maladaptations in the dopaminergic mesolimbic system, abnormal plastic changes in rewardspecial edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.7 dhr proceedings ǀ http://dhrproceedings.org 58 2024, vol. 4 no. s1 pg. 55-62 related brain areas, and genetic and epigenetic factors may contribute to alcohol reinforcement and addiction.1 research on adolescent mice has shown that adolescents exhibit resilience to alcohol withdrawal-induced changes in glutamate function in the nucleus accumbens, unlike adults, suggesting age-related differences in neurobiobehavioral responses to alcohol.15 the study by sinha highlights the role of chronic stress in addiction and substance abuse, emphasizing the alteration in the hpa axis and autonomic arousal linked to early life stress and its impact on drug use.16 these neurochemical changes underscore the complexity of alcohol's effects on the brain and the need for further research to understand the specific mechanisms involved. risk and protective factors several risk and protective factors influence the development of alcohol abuse and its neurodevelopmental consequences in hispanic adolescents in the rio grande valley. socioeconomic factors, including poverty and limited access to resources, may increase vulnerability to alcohol abuse.4,17,18 cultural factors, such as acculturation and family traditions surrounding alcohol consumption, also play a significant role.4 parental attitudes toward alcohol use, parental education level, and family support systems can impact adolescent drinking behavior.18-19 peer influence, school environment, and community-level factors all contribute to the complex interplay of risk factors.19-20 conversely, protective factors, such as strong family bonds, positive peer relationships, school connectedness, and engagement in prosocial activities, can buffer against alcohol abuse.19-20 the study by zucker et al. highlights the importance of early developmental processes, noting that developmental pathways to underage drinking often begin in early childhood and involve numerous risk and vulnerability factors.21 this underscores the need for comprehensive prevention strategies that address multiple risk factors across different developmental stages. the study by assari found that parental educational attainment affects youth inhibitory control, which in turn predicts high-risk behaviors, including substance use.18 however, there were diminished returns for non-hispanic black youth regarding the positive effects of parental education on behaviors compared to non-hispanic white youth, suggesting the need to address societal barriers that hinder the effectiveness of family resources.18 research gaps and future directions despite the existing literature, significant research gaps remain concerning the neurodevelopmental consequences of alcohol abuse in hispanic adolescents in the rio grande valley. more research is needed to: characterize alcohol use patterns: detailed epidemiological studies are needed to precisely define the prevalence, patterns, and types of alcohol use within this specific population. this special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.7 dhr proceedings ǀ http://dhrproceedings.org 59 2024, vol. 4 no. s1 pg. 55-62 would involve collecting data on binge drinking frequency, quantity of alcohol consumed, and age of initiation. investigate specific neurocognitive deficits: further research should utilize neuropsychological assessments to identify specific cognitive deficits associated with alcohol abuse in hispanic adolescents in the rio grande valley, focusing on executive functions, memory, attention, and processing speed. assess structural brain changes: more neuroimaging studies, such as mri and dti, are necessary to determine the specific structural brain changes associated with alcohol abuse in this population, comparing them to age-matched controls and considering potential confounding factors such as socioeconomic status, acculturation, and co-occurring mental health disorders. explore neurochemical mechanisms: research should examine the neurochemical mechanisms underlying alcohol's effects on the developing brain in hispanic adolescents. this would involve investigating alterations in neurotransmitter systems, gene expression, and cellular processes. evaluate the impact of cultural and socioeconomic factors: studies should examine how cultural factors (e.g., acculturation, family traditions) and socioeconomic factors (e.g., poverty, access to resources) interact with alcohol abuse to influence neurodevelopmental outcomes. develop culturally appropriate interventions: research should focus on developing and testing culturally appropriate prevention and intervention programs for hispanic adolescents in the rio grande valley. these programs should consider the unique cultural contexts and address multiple risk and protective factors. conduct longitudinal studies: longitudinal studies are crucial to understanding the long-term neurodevelopmental consequences of alcohol abuse, tracking cognitive and structural brain changes over time, and examining the impact on academic achievement, mental health, and social adjustment. conclusion alcohol abuse during adolescence poses significant neurodevelopmental risks, impacting both cognitive function and brain structure. while existing research provides valuable insights into the effects of alcohol on the developing brain, more targeted studies are needed to understand the specific consequences for hispanic adolescents in the rio grande valley. addressing the identified research gaps will enable the development of effective prevention and intervention strategies tailored to this population, ultimately promoting their long-term health and well-being. the unique social, cultural, and economic factors within this community must be considered to create culturally sensitive and effective interventions. the integration of epidemiological data, neuropsychological assessments, neuroimaging techniques, and a strong focus on community special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.7 dhr proceedings ǀ http://dhrproceedings.org 60 2024, vol. 4 no. s1 pg. 55-62 engagement are essential for advancing our understanding of this critical public health issue. further research will be vital in understanding the complex interplay between alcohol abuse, cultural factors, and neurodevelopment within this vulnerable population. only through a comprehensive approach incorporating multiple disciplines can effective strategies be developed to mitigate the long-term consequences of alcohol abuse on the lives of hispanic adolescents in the rio grande valley. acknowledgments nori zapata, msn, rn, senior vice president of education and career development, vanessa vera, ms, senior manager of high school and community outreach, anisa mirza, intern program coordinator. funding funded by dhr health high school and community outreach; dhr health; south texas independent school district. references 1. alfonso-loeches s, guerri c. molecular and behavioral aspects of the actions of alcohol on the adult and developing brain. critical reviews in clinical laboratory sciences. 2011;48(1):19-47. doi:https://doi.org/10.3109/10408363.2011.580567 2. crespi c, galandra c, manera m, basso g, poggi p, canessa n. executive impairment in alcohol use disorder reflects structural changes in large-scale brain networks: a joint independent component analysis on gray-matter and white-matter features. frontiers in psychology. 2019;10. doi:https://doi.org/10.3389/fpsyg.2019.02479 3. lisdahl km, gilbart er, wright ne, shollenbarger s. dare to delay? the impacts of adolescent alcohol and marijuana use onset on cognition, brain structure, and function. frontiers in psychiatry. 2013;4. doi:https://doi.org/10.3389/fpsyt.2013.00053 4. caetano r, ramisetty-mikler s, wallisch ls, mcgrath c, spence rt. acculturation, drinking, and alcohol abuse and dependence among hispanics in the texas-mexico border. alcoholism: clinical and experimental research. 2008;32(2):314-321. doi:https://doi.org/10.1111/j.1530-0277.2007.00576.x 5. courtney ke, polich j. binge drinking in young adults: data, definitions, and determinants. psychological bulletin. 2009;135(1):142-156. doi:https://doi.org/10.1037/a0014414 6. miranda r, monti pm, ray l, et al. characterizing subjective responses to alcohol among adolescent problem drinkers. journal of abnormal psychology. 2014;123(1):117129. doi:https://doi.org/10.1037/a0035328 https://doi.org/10.3109/10408363.2011.580567 https://doi.org/10.3389/fpsyg.2019.02479 https://doi.org/10.3389/fpsyt.2013.00053 https://doi.org/10.1111/j.1530-0277.2007.00576.x https://doi.org/10.1037/a0014414 https://doi.org/10.1037/a0035328 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.7 dhr proceedings ǀ http://dhrproceedings.org 61 2024, vol. 4 no. s1 pg. 55-62 7. lópez-caneda e, rodríguez holguín s, correas á, et al. binge drinking affects brain oscillations linked to motor inhibition and execution. journal of psychopharmacology. 2017;31(7):873-882. doi:https://doi.org/10.1177/0269881116689258 8. lópez-caneda e, rodríguez holguín s, cadaveira f, corral m, doallo s. impact of alcohol use on inhibitory control (and vice versa) during adolescence and young adulthood: a review. alcohol and alcoholism. 2013;49(2):173-181. doi:https://doi.org/10.1093/alcalc/agt168 9. morin jfg, afzali mh, bourque j, et al. a population-based analysis of the relationship between substance use and adolescent cognitive development. american journal of psychiatry. 2019;176(2):98-106. doi:https://doi.org/10.1176/appi.ajp.2018.18020202 10. fritz m, klawonn am, zahr nm. neuroimaging in alcohol use disorder: from mouse to man. journal of neuroscience research. 2019;100(5):1140-1158. doi:https://doi.org/10.1002/jnr.24423 11. logtenberg e, overbeek mf, pasman ja, et al. investigating the causal nature of the relationship of subcortical brain volume with smoking and alcohol use. the british journal of psychiatry. 2021;221(1):377-385. doi:https://doi.org/10.1192/bjp.2021.81 12. lebel c, mattson sn, riley ep, et al. a longitudinal study of the long-term consequences of drinking during pregnancy: heavy in utero alcohol exposure disrupts the normal processes of brain development. journal of neuroscience. 2012;32(44):15243-15251. doi:https://doi.org/10.1523/jneurosci.1161-12.2012 13. durazzo tc, mon a, gazdzinski s, meyerhoff dj. regional brain volume changes in alcohol-dependent individuals during early abstinence: associations with relapse following treatment. addiction biology. 2016;22(5):1416-1425. doi:https://doi.org/10.1111/adb.12420 14. de santis s, bach p, pérez-cervera l, et al. microstructural white matter alterations in men with alcohol use disorder and rats with excessive alcohol consumption during early abstinence. jama psychiatry. 2019;76(7):749. doi:https://doi.org/10.1001/jamapsychiatry.2019.0318 15. lee km, coelho ma, mcgregor ha, solton nr, cohen mj, szumlinski kk. adolescent mice are resilient to alcohol withdrawal-induced anxiety and changes in indices of glutamate function within the nucleus accumbens. frontiers in cellular neuroscience. 2016;10. doi:https://doi.org/10.3389/fncel.2016.00265 16. sinha r. chronic stress, drug use, and vulnerability to addiction. annals of the new york academy of sciences. 2008;1141(1):105-130. doi:https://doi.org/10.1196/annals.1441.030 17. jokinen t, alexander ec, manikam l, et al. a systematic review of household and family alcohol use and adolescent behavioural outcomes in lowand middle-income https://doi.org/10.1177/0269881116689258 https://doi.org/10.1093/alcalc/agt168 https://doi.org/10.1176/appi.ajp.2018.18020202 https://doi.org/10.1002/jnr.24423 https://doi.org/10.1192/bjp.2021.81 https://doi.org/10.1523/jneurosci.1161-12.2012 https://doi.org/10.1111/adb.12420 https://doi.org/10.1001/jamapsychiatry.2019.0318 https://doi.org/10.3389/fncel.2016.00265 https://doi.org/10.1196/annals.1441.030 special edition: advanced clinical research internship session iii (2024), vol. 4 no. s2 https://doi.org/10.47488/dhrp.v4is2.7 dhr proceedings ǀ http://dhrproceedings.org 62 2024, vol. 4 no. s1 pg. 55-62 countries. child psychiatry & human development. 2020;52(4):554-570. doi:https://doi.org/10.1007/s10578-020-01038-w 18. assari s. parental education and youth inhibitory control in the adolescent brain cognitive development (abcd) study: blacks’ diminished returns. brain sciences. 2020;10(5):312. doi:https://doi.org/10.3390/brainsci10050312 19. nath a, choudhari sg, dakhode su, rannaware a, gaidhane am. substance abuse amongst adolescents: an issue of public health significance. cureus. 2022;14(11). doi:https://doi.org/10.7759/cureus.31193 20. shochet im, dadds mr, ham d, montague r. school connectedness is an underemphasized parameter in adolescent mental health: results of a community prediction study. journal of clinical child & adolescent psychology. 2006;35(2):170179. doi:https://doi.org/10.1207/s15374424jccp3502_1 21. zucker ra, donovan je, masten as, mattson me, moss hb. early developmental processes and the continuity of risk for underage drinking and problem drinking. pediatrics. 2008;121(supplement 4):s252-s272. doi:https://doi.org/10.1542/peds.20072243b https://doi.org/10.1007/s10578-020-01038-w https://doi.org/10.3390/brainsci10050312 https://doi.org/10.7759/cureus.31193 https://doi.org/10.1207/s15374424jccp3502_1 https://doi.org/10.1542/peds.2007-2243b https://doi.org/10.1542/peds.2007-2243b special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.92 dhr proceedings ǀ http://dhrproceedings.org 71 2023, vol. 2 no. s2 71-78 commentary the effects of anorexia on adolescents melanie acosta1,3, adalyn coronado1,4, isabela elizondo1,2, mahaa gondi1,5, miguel hernandez1,2, annalisa martinez1,4, jaiden mendoza1,2, brianna moreno1,3, alejandro reyes1,2, aliyah rodriguez1,4, annabella l. ruiz1,2, miranda sifuentes1,3, vanessa villegas1,3 1 3rdannual junior clinical research internship, south texas academy for education & training in research, dhr health institute for research and development 2 mcallen memorial high school, mcallen, tx 3 mission high school, mission, tx 4 rio hondo high school, rio hondo, tx 5 south texas isd health professions, mercedes, tx received: august 3, 2023 accepted for publication: november 6, 2023 published: november 16, 2023 introduction according to missouri baptist university researchers, in the united states, 95% of the people that have an eating disorder are from ages 12 through 25.1 eating disorders are a heavily misunderstood subject throughout the world. commonly, many people deny the prominence of eating disorders, leading to a major effect on adolescents. due to this, many adolescents suffer from this disorder alone and without help. in a national statistic reported by the national library of medicine, it was found that 3-20% of all eating disorders lead to death.2 the recognition of the causes and effects of eating disorders is imperative because the more society understands, there will be a greater sense of awareness to help prevent the increase of fatal eating disorders. what is anorexia? anorexia nervosa, or anorexia is typically defined as the neurotic loss of appetite.3 anorexia, in other words, is a mental disorder that leads an individual to constantly think about their weight and body shape from a negative perception created through the patient’s brain.4 anorexia, in some cases, is known to stem from small habits and evolves into a larger issue, eventually leading to several risk factors which affect a patient’s quality of life. in critical cases, anorexia nervosa may lead to hospitalization, a variety of health issues, and even death. anorexia is acknowledged to have the highest death rate compared to other mental disorders.5 anorexia is also commonly known for permanently affecting a patient’s brain negatively, in most cases, for the rest of their lives. anorexia is not usually spoken about socially, as patients with anorexia will not speak about their illness, especially if they are aware of the issue. diagnosis currently, the most reliable method of diagnosis for anorexia patients is the diagnostic and statistical manual of mental health disorders, 5th edition (dsm-5tr). the dsm-5tr is the most recent and relevant publication for diagnosis which covers anorexia symptoms in detail and variety, as anorexia symptoms vary from person to person. a patient must fit the three main criteria according to the dsm-5-tr for anorexia to be diagnosed: restriction, fear, and lack of recognition.6 restriction is shown through a patient’s habit of restricting calorie intake, based on the individual’s body mass index (bmi). fear is presented in an individual’s mental perception of body weight. lack of recognition is exhibited through the development of body dysmorphia, leading to a warped perception of the severity of their circumstances.7 symptoms anorexia is an illness that begins psychologically and progresses to various physical special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.92 dhr proceedings ǀ http://dhrproceedings.org 72 2023, vol. 2 no. s2 71-78 components. common physical and psychological symptoms of anorexia include but are not limited to, frequent headaches, dizziness, anemia, loss of muscle mass, irritability, excessive hair loss, loss of a woman’s menstrual cycle, constipation, fatigue, nausea, and lanugo.8 medical complications anorexia is commonly conceptualized as being connected to other mental and physical disorders, many of which come as a future result of malnutrition and a consequence of insufficient vitamin and mineral intake. anorexia is known to affect adolescence the most in the long term, as several organs in the body are affected through future growth and development.9 with time, anorexia is known for causing other medical problems such as anemia, muscle weakness, infertility, osteoporosis, damage to the heart, damage to the brain, and multi-organ failure.10 since the human body develops the most during adolescence, anorexia is known for delaying puberty. in females, anorexia permanently affects fertility, as hormones and nutrients necessary for growth and development are not available. other minor medical complications that may arise from long-term anorexia in adolescence are carotenoderma, hyperpigmentation, excessive acne, dermatitis, paronychia, and striae distensae.11 psychologically, many comorbid disorders arise as a result of anorexia. mood disorders are the most common comorbid disorders of anorexia nervosa at 60.4%. many mood disorders which arise from anorexia include depression, general anxiety, personality disorders, and many phobias which correlate to eating or weight gain.12 prevalence due to social and psychological factors, 2.7% of adolescents are diagnosed with anorexia nervosa with lifetime prevalence of 0.3%.13,14 according to newport academy, anorexia is most prevalent in teenagers than adults and children. adolescence is a common time for the onset of anorexia nervosa. though social media was created to be a place for joyful communication and memories, many teens from the ages of 13-18 have admitted to being socially influenced.15 as a result, media influence has increased low self-esteem, stress, and anxiety, making it the largest risk range for those who have anorexia. the widespread use of social media, such as tumblr or instagram, can give adolescents an unrealistic view of their bodies and lead to eating disorders such as anorexia to fit that view. with women and teen girls being more commonly diagnosed with anorexia, it is crucial to remember that females are not the only ones. according to newport academy, 10% of teenage males are diagnosed with anorexia.16 factors like shame, denial, or a lack of knowledge about the severity of their problem, have many adolescents going untreated or choosing not to seek treatment. neurobiological aspects of anorexia cognitive and physiological background anorexia nervosa alters the way one discerns food. for instance, a study using magnetic resonance imaging on female patients with acute anorexia alongside patients without anorexia found that when patients were shown photos of high-caloric drinks, the hippocampus and the left amygdala of the brain exhibited signs of activity.17 other studies show increased activation of both the left and right amygdala.18 the left amygdala is associated with sustained and verbal emotions, while the right amygdala is associated with dynamic and visual emotions, and the hippocampus plays a vital role in memory and learning. the response displayed by the patients with anorexia was the same as that of individuals who had an aversion to a phobia, in contrast to patients who were healthy and expressed delight or neutrality.19 many functional magnetic resonance imaging studies found that because of a lack of nutrition, patients with anorexia also had decreased gray and white brain matter.20 these fmri studies also show that the disorder alters the brain activity in the cingulate cortex which is responsible for linking reward and punishment information. limbic and cognitive pathways have been highlighted in research for structural and functional differences in someone who has anorexia inclusive of neurochemical changes. according to other studies, there have been abnormalities in the orbitofrontal cortex. its function is to signal when to stop eating, while the dorsal striatum controls habitual behaviors. the altering of the right insula controls and alters your perception of taste.21 utilizing neuroimaging, researchers and scientists have found that there is a change in gray matter volume and cortical thickness within the brain. these results show us that restricting food intake does affect brain structure and function.22 the brain’s reward systems and how they come into play in neurochemistry according to the national association of anorexia nervosa and associated disorders, when special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.92 dhr proceedings ǀ http://dhrproceedings.org 73 2023, vol. 2 no. s2 71-78 dopamine is released from the dorsal striatum of an anorexic person, it causes anxiety instead of satisfaction or pleasure.23 for example, an individual without anorexia may eat a serving of cake and will be motivated by dopamine to have a second serving. however, in the mind of someone with anorexia nervosa, the motivation given by dopamine forgoes its function. in the mind of an individual with anorexia, the process of eating is broken down, making it difficult to understand the reward processing and how to learn from the rewards.24 due to this, patients become highly sensitive to punishment. a study done based on animal models showed that there are projections from the hypothalamus to the nucleus accumbens (nac).25 the nac indicates reward in conducting natural behaviors such as sex, exercise, and in particular, feeding. as shown in fig. 1, there are neural pathways specific to eating disorders. nac is involved in mediating emotion and motivation. the mesolimbic system transports dopamine to the nac and is involved in pleasurable sensations. it is also a location for endogenous opioids to module dopamine (da) release and orosensory—relating to oral innervation—reward process.26 serotonin (5-ht) also plays a big role in feeding behavior, being related to your satiety. in conclusion, behavioral neuroscience suggests that there is dysregulation of the reward systems in your neurotransmitters shown by studies utilizing people who have eating disorders such as anorexia nervosa.27 dopamine (blue), serotonin (green), acetylcholine (red) and opioids (orange) have each been indicated in disordered eating. this schematic illustrates some of the neuronal projections that research indicates are of particular interest in the regulation.28 cultural influences western culture western culture tends to glorify small and slim bodies. the prevalence of obesity and being overweight, despite affecting a majority of the population, remains stigmatized. the origin of this unknown bias has caused many adolescents to develop problems such as body dysmorphia and internalized societal expectations. especially within social media, the unrealistic bodies depicted cause many to engage in dieting and weight loss to conform to societal expectations.29 western culture tends to associate slimness with power and self-discipline, compared to other cultures like the samoan culture which emphasizes the importance of nutrition and eating a variety of foods. asian culture asian culture is collectivistic, meaning that group autonomy is underscored while individual autonomy is not the community’s main priority. for this reason, pressure is set on individuals to fit into cultural and societal norms. another idea that asian culture emphasizes is the idea of 'filial piety’, which is having an immense amount of respect for elders, which may create pressure on individuals to conform to societal norms, including body image standards. for example, in thailand, various stores for plus-sized individuals are called “moo moo” and “love calories”, in an effort to degrade them.30 diet culture diet culture is a way of life that groups unhealthy foods with fatness and healthy foods with thinness. individuals who follow diet culture tend to comment on others' weight loss and thinness, while also bashing those who eat unhealthy or maybe are overweight. many who follow diet culture are fearful of weight gain and look down on gaining weight. diet culture is not just that, diet culture also instills fear in others of weight gain, one of the diagnostic criteria for anorexia.31 diet culture: an early beginning during the 19th century, also known as the victorian era, diet culture began to take a prominent role in society. this era saw rises in many young women's restrictive patterns mostly due to the emergence of many obsessions with achieving an hourglass silhouette.32 during this era, many ate small portions of bland food while avoiding more indulgent special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.92 dhr proceedings ǀ http://dhrproceedings.org 74 2023, vol. 2 no. s2 71-78 dishes. corsets also reinforced eating smaller portions and having a perfect body. there was immense pressure, mentally and physically, to conform to societal standards, which in turn caused these individuals to suffer from malnutrition and eating disorders. diet culture: 20th century the 20th century marked a turning point in the history of diet culture. with the rise of mass media, beauty standards became heavily influenced by hollywood films and advertisements. slim figures were idealized and equated with success and desirability. this led to the emergence of countless diet products, programs, and fads promising quick weight loss and a perfect silhouette.33 diet culture: 21st century the 21st century has undergone immense industrialization and many other changes. one of the main factors contributing to the rise of dieting and eating disorders today is the availability of information via technology.34 adolescents today have easy access and are exposed to a wealth of online resources that claim to provide advice on weight loss and "perfect" body ideals. many times, this information is misleading, contributing to distorted body image perceptions and promoting unhealthy habits. social influences many individuals on the social media app called “tiktok” have gone out of their way to create pro-anorexia accounts, where information about weight loss and weight loss methods are shared and encouraged. these accounts, often called “pro-ana” or “mia” accounts, can be dangerous. they can be viewed or interacted with, whereby the app's algorithm will continue to advertise these videos to adolescents. this may influence adolescents to engage in disordered eating or develop body image issues. for this reason, about 81% of 10-year-olds are afraid of being fat.35 predisposing adolescents to this sort of behavior could later manifest into a greater fear of gaining weight, and exposing them to disordered eating. via their tv show “keeping up with the kardashians” and social media apps such as instagram, the kardashian family has been able to influence others into striving to look like them, despite their family having undergone a variety of surgical procedures. their social media platforms and reality tv shows showcase their glamorous lifestyles, which often include a consistent emphasis on their body sizes and appearances. adolescents, who are in a vulnerable period of self-discovery, tend to be heavily influenced by these unrealistic beauty standards promoted by kardashian influencers. one element that the kardashian family has gone under scrutiny for is photoshopping on instagram. on several occasions the family has been caught using facetune to shrink their waists, make their lips bigger, widen their hips, and then lying about editing their photos, causing their viewers to want to reach an unrealistic body image. along with their photo editing, the family has denied their use of botox and other procedures which further make their viewers believe that their bodies are somehow achievable through natural remedies. other influencers like gigi and bella hadid are idolized for their slender physique, further glorifying the concept of being skinny. designers like karl lagerfeld and fashion magazines like vogue have indirectly contributed to this culture by showcasing predominantly slim figures. this can be detrimental especially since 69% of girls in 5th-12th grade reported that magazine pictures influenced their idea of a perfect body shape”.36 the fashion industry has long been known for promoting thinness as the ideal body type, using underweight models in runway shows and advertising campaigns. playboy magazine, a very influential magazine, has also been known to hire underweight models. according to the national institute of health, 75% of these women were less than 85% of their ideal body weight.37 these social influences may be a cause and the reason why adolescents engage in risky behavior to reach an unrealistic body standard. management and treatments patients with anorexia only recognize the disorder when the mental illness is dangerous or lifethreatening, therefore it is strongly emphasized that the illness should be caught in the early stages. management and treatments for anorexia range from physiological therapy to hospitalization.38 typical treatments for eating disorders such as anorexia consist of different types of therapy, education on the disorder, and medication. some of the different types of therapies include cognitive behavioral therapy, family-based therapy, and psychotherapy.39 these different types of therapies focus on the patient's mental as well as physical wellbeing. for instance, cognitive behavioral therapy is a type of psychotherapy focusing on the mental health of the patient. it focuses on the patient's behaviors, special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.92 dhr proceedings ǀ http://dhrproceedings.org 75 2023, vol. 2 no. s2 71-78 thoughts, and feelings related to their eating disorder.40 after helping the patient change their eating habits, cognitive behavioral therapy helps the patient acknowledge and adjust the twisted thoughts that originally led to developing anorexia.41 education and awareness are also important elements to help address anorexia. one way the patient or a family member could educate themselves is to research different ways to manage it. a few techniques they could implement to help manage anorexia involve nutritional management, terminating purging behaviors, and seeking professional help from dietitians.42 with the help of professional dietitians, the patient can work on both nutritional management and putting a stop to purging behaviors.43 professional dietitians help by providing counsel to help patients with their eating behaviors. they accomplish this by providing individualized meal plans and suggestions on different meals that the patient could start with, as they begin their “healing” and improvement journey. even though there are no notable medications that could “fix’’ anorexia, there are a variety of therapies that can help treat as well as manage those who are diagnosed with anorexia. for instance, in older generations, doctors used a variety of different methods/therapies that they claimed would help their patients. unfortunately, most of these methods ended up affecting the patients even more, and would sometimes even lead to their deaths. some of the therapies that specialists used to use include parentectomy, lobotomies, shock therapy, and neuromodulation. parentectomy is the removal of the parents from the teen's life in order to check for any improvement in their physical and mental health. by withdrawing the parents from the teen’s life the specialists hoped that the patients would improve mentally and begin eating more. lobotomy therapy/lobotomy is a procedure in which specialists split the white fibers of the frontal lobes to stop illnesses and make them go away.44 lobotomies have caused many controversies throughout the years and have been widely considered to be one of the craziest procedures one could get back then to try to fix their mental illnesses. it is well known that anorexia was sometimes dealt with by lobotomies. however, it is also known that lobotomies didn’t have the best effects. most of the time, lobotomies didn’t work and would have serious consequences on the individual's intellect and personality.45 shock therapy was also a common way to deal with mental and physical illnesses such as anorexia. shock therapy is the use of electroconvulsive therapy to improve severe mental issues and their symptoms.46 shock therapy was well known for providing rapid relief and improvements of some serious and severe mental conditions.47 it was also known that, although not typically used to treat anorexia, in some cases it helped “fix’’ it. finally, unlike the previous methods and therapies, neuromodulation was one of the least common practices used to treat anorexia and it was typically only used in hard-to-treat cases.48 neuromodulation is a procedure done by altering nerve activity through targeted stimuli such as shock stimulation or by the use of chemical agents.49 although sometimes not successful, it would typically alter the brain in a way that the patient's depressive and anxiety symptoms were long gone. after the procedures, it was also observed that with time, the patient's weight was restored up to 20%. the treatments used today are family-based therapy and psychotherapy. family-based therapy is when family members help the patient learn healthy eating habits until the patient can get to a healthy state in their weight and get rid of the unhealthy habits.50 the parents also help the child by controlling the patient's diet and what they need to eat and help them listen to their body and get them the nutrients they need. psychotherapy is a form of therapy that helps the patient recognize the problem and helps control the patient's emotions and feelings.51 this therapy helps anorexic patients learn about themselves and understand why it happens. they do this to help overcome challenges in the patient's daily life. this helps people become more confident in themselves and can help the patient get better.52 conclusion the causes and effects of anorexia have a significant on society, specifically among adolescents. it is crucial to spread awareness of this disorder across america to prevent more adolescents from falling into the trap of a false reality that will cause horrible consequences. fortunately, in recent years, there has been an emergence of new uses for existing medications such as olanzapine, traditionally used to manage schizophrenia. this research has demonstrated a potential to help manage symptoms of anorexia including an association with bmi increase and better sleep quality.15 this new research has caused promising results in the treatment of anorexia which can be a big breakthrough in the management of this disorder. special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.92 dhr proceedings ǀ http://dhrproceedings.org 76 2023, vol. 2 no. s2 71-78 acknowledgements monica betancourt-garcia, md, program director; melissa eddy, ms, program manager funding funded by dhr health institute for research & development; dhr health; region one esc gearup college ready, career set!; region one esc gearup college now, career connected; region one esc paths; region one esc upward bound math & science; benavides isd; and jubilee academy-brownsville references 1. (n.d.). eating disorders. retrieved july 26, 2023, from https://www.mobap.edu/wpcontent/uploads/2013/01/nedsp2007_eating_ disorders_fact_sheet.pdf 2. patel, r. s., machado, t., & tankersley, w. e. (2021). eating disorders and suicidal behaviors in adolescents with major depression: insights from the us hospitals. behavioral sciences (basel, switzerland), 11(5), 78. https://doi.org/10.3390/bs11050078 3. moskowitz, lindsay, and eric weiselberg. “anorexia nervosa/atypical anorexia nervosa.” current problems in pediatric and adolescent health care, vol. 47, no. 4, apr. 2017, pp. 70–84, https://doi.org/10.1016/j.cppeds.2017.02.003 . 4. berger, fred k. “anorexia: medlineplus medical encyclopedia.” medlineplus.gov, 2013, medlineplus.gov/ency/article/000362.htm. 5. medline plus. “eating disorders.” medlineplus.gov, national library of medicine, 2019, medlineplus.gov/eatingdisorders.html. 6. nall, rachel. “anorexia nervosa bingeeating purging dsm 5.” symptom media, 27 mar. 2018, symptommedia.com/dsm-5guided-anorexia-nervosa-binge-eatingpurging-film-preview/. 7. nall, rachel. “anorexia nervosa bingeeating purging dsm 5.” symptom media, 27 mar. 2018, symptommedia.com/dsm-5guided-anorexia-nervosa-binge-eatingpurging-film-preview/. 8. peterson k, fuller r. anorexia nervosa in adolescents: an overview. nursing. 2019 oct;49(10):24-30. doi: 10.1097/01.nurse.0000580640.43071.15. pmid: 31568077. 9. n, d. “stanford children’s health.” stanfordchildrens.org, 2016, www.stanfordchildrens.org/en/topic/default? id=anorexia-nervosa-in-children-90-p02554. 10. medline plus. “eating disorders.” medlineplus.gov, national library of medicine, 2019, medlineplus.gov/eatingdisorders.html. 11. peterson k, fuller r. anorexia nervosa in adolescents: an overview. nursing. 2019 oct;49(10):24-30. doi: 10.1097/01.nurse.0000580640.43071.15. pmid: 31568077. 12. marucci, simonetta, et al. “anorexia nervosa and comorbid psychopathology.” endocrine, metabolic & immune disorders drug targets, vol. 18, no. 4, 12 june 2018, pp. 316–324, www.ingentaconnect.com/contentone/ben/e middt/2018/00000018/00000004/art00006, https://doi.org/10.2174/18715303186661802 13111637. 13. rittenhouse, margot. “eating disorders in teens.” eating disorder hope, 4 aug. 2021, www.eatingdisorderhope.com/riskgroups/eating-disorders-teens. 14. swanson, sonja a. “prevalence and correlates of eating disorders in adolescents.” archives of general psychiatry, vol. 68, no. 7, 1 july 2011, p. 714, https://doi.org/10.1001/archgenpsychiatry.2 011.22. 15. newport academy. “teen anorexia statistics.” newport academy, 28 feb. 2012, www.newportacademy.com/resources/treat ment/teen-anorexia-statistics/. 16. newport academy. “teen anorexia statistics.” newport academy, 28 feb. 2012, www.newportacademy.com/resources/treat ment/teen-anorexia-statistics/. 17. dahleen h, mao d the neurobiology of anorexia nervosa. grey matters. published february 9, 2023, https://greymattersjournal.org/anorexia/. 18. dahleen h, mao d the neurobiology of anorexia nervosa. grey matters. published february 9, 2023, https://greymattersjournal.org/anorexia/. 19. dahleen h, mao d the neurobiology of anorexia nervosa. grey matters. published special edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.92 dhr proceedings ǀ http://dhrproceedings.org 77 2023, vol. 2 no. s2 71-78 february 9, 2023, https://greymattersjournal.org/anorexia/. 20. scharner, sophie, and andreas stengel. “alterations of brain structure and functions in anorexia nervosa.” clinical nutrition experimental, vol. 28, feb. 2019, https://doi.org/10.1016/j.yclnex.2019.02.001 . 21. slawsky, lynn. “neurobiology of eating disorders.” national association of anorexia nervosa and associated disorders, 8 feb. 2021, anad.org/neurobiology-ofeating-disorders/. 22. frank, guido k.w. “neuroimaging and eating disorders.” current opinion in psychiatry, vol. 32, no. 6, nov. 2019, pp. 478–483, https://doi.org/10.1097/yco.0000000000000 544. 23. weir, kirsten. “new insights on eating disorders.” https://www.apa.org, apr. 2016, www.apa.org/monitor/2016/04/eatingdisorders. 24. slawsky, lynn. “neurobiology of eating disorders.” national association of anorexia nervosa and associated disorders, 8 feb. 2021, anad.org/neurobiology-ofeating-disorders/. 25. yoshida k, mccormack s, espana ra, crocker a, scammell te. afferents to the orexin neurons of the rat brain. j comp neurol. 2006;494:845–861. 26. wise ra. role of brain dopamine in food reward and reinforcement. philos trans r soc lond b biol sci. 2006;361:1149–1158. 27. halford jc, blundell je. separate systems for serotonin and leptin in appetite control. ann med. 2000b;32:222–232. 28. avena, nicole m., and miriam e. bocarsly. “dysregulation of brain reward systems in eating disorders: neurochemical information from animal models of binge eating, bulimia nervosa, and anorexia nervosa.” neuropharmacology, vol. 63, no. 1, july 2012, pp. 87–96, https://doi.org/10.1016/j.neuropharm.2011.1 1.010. 29. logrieco g, marchili mr, roversi m, villani a. the paradox of tik tok anti-proanorexia videos: how social media can promote non-suicidal self-injury and anorexia. int j environ res public health. 2021;18(3):1041. published 2021 jan 25. doi:10.3390/ijerph18031041 30. archive va, twitter f on, feed g author r. plus-size clothing stores called “fat girls” and “moo moo” in thailand. published march 24, 2023. https://nypost.com/2023/03/24/plus-sizeclothing-stores-called-fat-girls-and-moomoo-in-thailand/ 31. archive va, twitter f on, feed g author r. plus-size clothing stores called “fat girls” and “moo moo” in thailand. published march 24, 2023. accessed august 2, 2023. https://nypost.com/2023/03/24/plus-sizeclothing-stores-called-fat-girls-and-moomoo-in-thailand/ 32. chastain r. recognizing and resisting diet culture. national eating disorders association. may 2, 2019. accessed august 2, 2023. https://www.nationaleatingdisorders.org/blo g/recognizing-and-resisting-diet-culture. 33. diet culture throughout history. embody health london. published september 13, 2022. accessed august 2, 2023. https://embodyhealthlondon.com/dietculture-throughout-history/ 34. diet culture throughout history. embody health london. published september 13, 2022. accessed august 2, 2023. https://embodyhealthlondon.com/dietculture-throughout-history/ 35. morris am, katzman dk. the impact of the media on eating disorders in children and adolescents. paediatr child health. 2003;8(5):287-289. doi:10.1093/pch/8.5.287 36. eating disorders. retrieved july 26, 2023, from https://www.mobap.edu/wpcontent/uploads/2013/01/nedsp2007_eating_ disorders_fact_sheet.pdf 37. eating disorders. retrieved july 26, 2023, from https://www.mobap.edu/wpcontent/uploads/2013/01/nedsp2007_eating_ disorders_fact_sheet.pdf 38. morris am, katzman dk. the impact of the media on eating disorders in children and adolescents. paediatr child health. 2003;8(5):287-289. doi:10.1093/pch/8.5.287 39. treasure, janet, and ulrike schmidt. “the cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socioemotional and interpersonal predisposing and perpetuating factors.” journal of eating disorders, vol. 1, no. 1, 15 apr. 2013, https://doi.org/10.1186/2050-2974-1-13. 40. eating disorder treatment: know your options. mayo clinic. july 14, 2017. accessed july 31, 2023. https://www.mayoclinic.org/diseasesspecial edition: junior clinical research (2023), vol. 3 no. s2 https://doi.org/10.47488/dhrp.v3is2.92 dhr proceedings ǀ http://dhrproceedings.org 78 2023, vol. 2 no. s2 71-78 conditions/eating-disorders/in-depth/eatingdisorder-treatment/art-20046234. 41. voderholzer u, haas v, correll cu, körner t. medical management of eating disorders: an update. curr opin psychiatry. 2020;33(6):542-553. doi:10.1097/yco.0000000000000653 42. terrier lm, lévêque m, amelot a. brain lobotomy: a historical and moral dilemma with no alternative?. world neurosurg. 2019;132:211-218. doi:10.1016/j.wneu.2019.08.254 43. electroconvulsive therapy (ect). mayo clinic. october 12, 2018. accessed july 31, 2023. https://www.mayoclinic.org/testsprocedures/electroconvulsivetherapy/about/pac20393894#:~:text=why%20it’s%20done,sui cide%20or%20refusal%20to%20eat. 44. pacilio rm, livingston rk, gordon mr. the use of electroconvulsive therapy in eating disorders: a systematic literature review and case report. j ect. 2019;35(4):272-278. doi:10.1097/yct.0000000000000599 45. shafik boyaji m, pritesh topiwala m. pain and neuromodulation: what’s all the “buzz” about? harvard health. march 3, 2020. accessed july 31, 2023. https://www.health.harvard.edu/blog/painand-neuromodulation-whats-all-the-buzzabout-2020030318975. 46. gallop l, flynn m, campbell ic, schmidt u. neuromodulation and eating disorders. curr psychiatry rep. 2022;24(1):61-69. doi:10.1007/s11920-022-01321-8 47. garcia n. neuromodulation defined. international neuromodulation society. accessed august 2, 2023. https://www.neuromodulation.com/neuromo dulation-defined. 48. d. blake woodside m. eating disorders & neuromodulation: treating anorexia nervosa and bulimia. psychiatric times. march 3, 2023. accessed july 31, 2023. https://www.psychiatrictimes.com/view/eati ng-disorders-neuromodulation-treatinganorexia-nervosa-and-bulimia 49. garcia n. neuromodulation defined. international neuromodulation society. accessed august 2, 2023. https://www.neuromodulation.com/neuromo dulation-defined. 50. mayo clinic. “eating disorder treatment: know your options.” mayo clinic, 14 july 2017, www.mayoclinic.org/diseasesconditions/eating-disorders/in-depth/eatingdisorder-treatment/art-20046234. 51. “psychotherapy kelty eating disorders.” kelty eating disorders, 2016, keltyeatingdisorders.ca/treatmentoptions/psychotherapy/. 52. mayo clinic. “eating disorder treatment: know your options.” mayo clinic, 14 july 2017, www.mayoclinic.org/diseasesconditions/eating-disorders/in-depth/eatingdisorder-treatment/art-20046234. 