United States

An Expert-Validated Survey to Assess Lead Tethering Following Hypoglossal Nerve Stimulation Surgery

Authors: Rishi Raghavan, Roberto Spilka, Arman Saeedi, Mihai Bentan, Aaron Tucker, Maria Suurna, MD, Ryan Nord, MD
Background: 
Hypoglossal nerve stimulation (HNS) is an increasingly utilized treatment for obstructive sleep apnea (OSA), especially for patients who are unable to tolerate CPAP therapy. However, lead tethering—a mechanical complication causing neck tightness, discomfort, restricted mobility, or psychological distress—may negatively impact long-term postoperative outcomes. Despite anecdotal reports in clinical practice, no validated patient-reported outcome (PRO) instrument currently exists to assess these specific symptoms. This study aimed to develop and validate a concise, reliable survey to measure physical, cosmetic, and psychosocial effects associated with lead tethering following HNS implantation.
Methods: 
An initial 12-item survey was constructed through literature review and expert feedback, addressing domains of discomfort, appearance, movement limitation, and emotional response. Six specialists in otolaryngology and sleep medicine rated item relevance on a 4-point scale. Items with item-level content validity index (I-CVI) scores below 0.78 or deemed redundant were revised or removed, resulting in a final 5-item instrument. Twenty-eight HNS recipients completed the survey at two intervals separated by at least 2 weeks (mean: 4 weeks). A 4-point Likert scale captured responses. Test–retest reliability was assessed using Gwet’s AC2 with ordinal weights.
Results: 
All survey items demonstrated strong reliability across timepoints: neck appearance (AC2 = 0.895), tightness (0.778), movement restriction (0.771), interference with daily activities (0.881), and distress or anxiety (0.963); all p &lt; 0.001. Descriptive agreement analysis supported temporal consistency.
Conclusion: 
The findings support the reliability and content validity of a novel 5-item PRO instrument tailored for assessing lead tethering symptoms in HNS recipients. While additional validation in broader populations is recommended, the survey may offer a useful framework for postoperative monitoring and future research.


AMA Research Challenge 2025 

An Expert-Validated Survey to Assess Lead Tethering 
Following Hypoglossal Nerve Stimulation Surgery

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AMA Research Challenge 2022

Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


An Expert-Validated Survey to Assess Lead Tethering Following Hypoglossal Nerve Stimulation Surgery

Authors: Rishi Raghavan, Roberto Spilka, Arman Saeedi, Mihai Bentan, Aaron Tucker, Maria Suurna, MD, Ryan Nord, MD
Background: 
Hypoglossal nerve stimulation (HNS) is an increasingly utilized treatment for obstructive sleep apnea (OSA), especially for patients who are unable to tolerate CPAP therapy. However, lead tethering—a mechanical complication causing neck tightness, discomfort, restricted mobility, or psychological distress—may negatively impact long-term postoperative outcomes. Despite anecdotal reports in clinical practice, no validated patient-reported outcome (PRO) instrument currently exists to assess these specific symptoms. This study aimed to develop and validate a concise, reliable survey to measure physical, cosmetic, and psychosocial effects associated with lead tethering following HNS implantation.
Methods: 
An initial 12-item survey was constructed through literature review and expert feedback, addressing domains of discomfort, appearance, movement limitation, and emotional response. Six specialists in otolaryngology and sleep medicine rated item relevance on a 4-point scale. Items with item-level content validity index (I-CVI) scores below 0.78 or deemed redundant were revised or removed, resulting in a final 5-item instrument. Twenty-eight HNS recipients completed the survey at two intervals separated by at least 2 weeks (mean: 4 weeks). A 4-point Likert scale captured responses. Test–retest reliability was assessed using Gwet’s AC2 with ordinal weights.
Results: 
All survey items demonstrated strong reliability across timepoints: neck appearance (AC2 = 0.895), tightness (0.778), movement restriction (0.771), interference with daily activities (0.881), and distress or anxiety (0.963); all p < 0.001. Descriptive agreement analysis supported temporal consistency.
Conclusion: 
The findings support the reliability and content validity of a novel 5-item PRO instrument tailored for assessing lead tethering symptoms in HNS recipients. While additional validation in broader populations is recommended, the survey may offer a useful framework for postoperative monitoring and future research.


poster

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Background
One in four children experience emotional, physical, or sexual abuse, with negative impacts on development that persist into adulthood, including emotion dysregulation and cognitive control issues. However, there is little known about the association between childhood abuse with neural networks and psychological problems in late adulthood. Given the well-known link between childhood abuse and depression, this study examined the impact of abuse on resting-state functional connectivity (FC) in adults with late-life depression (LLD), and whether FC changes mediate the relationship between abuse and anger-hostility.

Methods
98 participants aged ≥60 years with LLD were recruited from the NBOLD clinical research cohort. Childhood abuse was assessed using the Adverse Childhood Experiences (ACEs) questionnaire and coded as a binary variable (0 = no abuse, 1 = any abuse). Anger-related emotion dysregulation was measured using the NEO-PI anger-hostility subscale (N2). Resting-state fMRI data was processed in CONN toolbox. A whole-brain ROI-to-ROI ANCOVA was performed to identify FC differences between abuse and non-abuse groups, controlling for age, gender, education, and baseline depression severity (measured by the Montgomery-Åsberg Depression Rating Scale). Significant FC values (FDR-corrected p < 0.05) were extracted, and linear regression was used to test for association with anger-hostility. A mediation analysis was conducted in Jamovi with FC as the mediator between abuse and N2.

Results
Participants with a history of childhood abuse showed greater FC between the right anterior supramarginal gyrus (aSMG) and right cerebellar lobule VI (T = 3.82, p = 0.0273), and between the right inferior frontal gyrus (IFG) pars opercularis and left cerebellar lobule X (T = 3.98, p = 0.0224). Childhood abuse was associated with higher anger-hostility scores (β = 0.322, p = 0.001). Only aSMG-cerebellum FC was significantly associated with anger-hostility (β = 0.285, p = 0.006) while IFG-cerebellum FC was not (β = 0.126, p = 0.281). Mediation analysis showed that aSMG-cerebellum FC partially mediated the relationship between childhood abuse and anger-hostility (β = 0.104, p = 0.026), though the direct effect of abuse on anger remained significant (β = 0.219, p = 0.035).

Conclusion
Altered aSMG-cerebellum FC, which has been found to be associated with depression and ADHD in adolescents, may represent a neurobiological pathway linking childhood abuse to anger-related emotional dysregulation in LLD. The persistence of a direct effect in the mediation analysis indicates other mediators involved in cognitive control deficits in emotion dysregulation (e.g., rumination) warrant investigation. Understanding this relationship may inform targeted treatments for trauma-exposed individuals.

Altered right aSMG-cerebellum functional connectivity partially mediates the association of childhood abuse with anger-related emotional dysregulation in adults with late-life depression

Background:
Ventricular tachyarrhythmias precipitate sudden cardiac death (SCD) which can be averted by implantable cardioverter-defibrillators (ICD). The growing number of ICD implantations also increases prevalence of complications including right ventricular lead dislodgement (RVLD). We discuss a case of an ICD RVLD causing repeated shocks and death.

Case Presentation:
A 51-year-old male with non-ischemic cardiomyopathy (LVEF 20% that had since recovered) and an ICD for primary prevention received multiple ICD shocks in rapid succession and presented in cardiac arrest. On arrival, he was defibrillated and treated with amiodarone with return of spontaneous circulation. Persistent ICD shocks during sinus tachycardia (ST) prompted ICD deactivation.
Interrogation revealed RVL oversensing of atrial depolarizations on the far-field channel, confirmed by surface ECG, causing 64 recurrent defibrillations before ICD deactivation. Radiography showed RVLD to the tricuspid annulus causing simultaneous detection of atrial and ventricular activation. Neurologic evaluation showed no brain activity, and care was withdrawn.

Discussion:
Upon recognizing RVLD, urgent device interrogation and ICD tachytherapy deactivation should follow. The ICD misinterpreted atrial events during ST as ventricular depolarizations while simultaneously sensing the RV, triggering inappropriate anti-tachycardia pacing. The device interpreted this as VF, leading to frequent defibrillations. In cases like this, the incidence of life-threatening presentations may be mitigated by optimizing guideline-directed medical therapy for cardiomyopathy prior to ICD implantation—potentially avoiding unnecessary prophylactic devices—and by conducting routine device interrogations to detect lead dysfunction before life-threatening events occur. This case emphasizes the need for selective implantation, routine follow-up, and rapid identification of electrophysiologic emergencies like RVLD.

Right Ventricular Lead Dislodgement Causing Inappropriate ICD Shocks and Cardiac Arrest

Background
Subacute cutaneous lupus erythematosus (SCLE) is a type of cutaneous lupus erythematosus that classically presents as a non-scarring, photosensitive rash. Anti-Ro/SSA antibodies are often present. It may be associated with systemic lupus erythematosus (SLE) but also occurs without systemic involvement. It has been estimated that up to 30% of all of all subacute cutaneous lupus erythematosus cases are drug-induced, with more than more than 100 drugs implicated. Proton pump inhibitors (PPIs) are a growing cause of drug-induced SCLE (DI-SCLE) and may be underrecognized. 

Case Presentation
A 72-year-old woman presented to the dermatologist with scaly, pink, annular, thin plaques diffusely on the upper and lower back, central upper chest, and less prominent on the abdomen, right arm, and thighs. She was found to have positive anti-SSA and anti-histone antibodies. Complete blood count was notable for lymphopenia, but she had otherwise normal anti-nuclear antibody levels, complement 3, complement 4, and creatinine. Initial rheumatology evaluation indicated idiopathic SCLE and the patient was to initiate hydroxychloroquine. Further review of her medication list revealed that the rash developed six months after initiating omeprazole for gastroesophageal reflux disease. Timeline and serology raised concern for DI-SCLE. Omeprazole was promptly discontinued and triamcinolone 0.1% ointment was initiated, leading to complete resolution of the rash. 

Discussion
Drug-induced SCLE is a well-described entity that may occur in the absence or presence of SLE. PPIs are among a growing cause, with omeprazole representing a common trigger. The mechanism may involve drug-induced photosensitization and immune activation in genetically predisposed individuals. The appearance of lower limb SCLE lesions has also been noted to be characteristic of PPI-induced SCLE. Clinicians may misinterpret these eruptions as presentations of idiopathic SCLE, however, temporal relationship to drug initiation along with resolution upon withdrawal supports a diagnosis of DI-SCLE. Recognition of DI-SCLE is essential to prevent chronicity and unnecessary immunosuppression. This case highlights the need for vigilance regarding drug-induced cutaneous manifestations. Omeprazole should be considered a potential trigger for SCLE. Prompt identification and withdrawal of the offending agent may lead to significant clinical improvement.

Recognition of PPI-Induced Subacute Cutaneous Lupus Erythematosus in Clinical Practice

Background: Colorectal cancer (CRC) poses a substantial and widespread threat to cancer-related mortality in both the United States and worldwide. In recent decades, there has been a noticeable uptick in its incidence among younger adults, prompting a reassessment of CRC screening guidelines. Studies have substantiated this trend of rising incidence among younger age groups particularly in the absence of heritable risk factors.

Case Presentation: We present a case of a 28-year-old male, with no familial history of CRC, who presented with chronic diarrhea, crampy abdominal pain, blood in the stools, weight loss and anemia for 6 months. The patient was previously treated with antibiotics, which provided only transient symptom relief. Notably, he has a history of marijuana use. Colonoscopy identified a substantial, obstructive polypoid mass located in the transverse colon leading to intermittent intussusception of the bowel segment. This condition led to the above-mentioned spectrum of symptoms. Subsequent biopsy of the colon mass confirmed the diagnosis of invasive, moderately differentiated adenocarcinoma. Immunohistochemical analysis for mismatch repair (MMR) proteins demonstrated a loss of nuclear expression of MLH1 and PMS2. The tumor was classified as microsatellite instability high. The patient underwent surgical resection followed by adjuvant chemotherapy, resulting in improved condition and ongoing monitoring.

Discussion: This case, characterized by the loss of MLH1 and PMS2 expression, highlights the importance of identifying molecular markers commonly associated with sporadic CRC. Understanding these molecular alterations can aid in distinguishing between sporadic and hereditary CRC, which is crucial for developing appropriate management strategies. This case underscores the necessity for further research into the environmental and lifestyle factors contributing to the increasing incidence of CRC in the young, as well as potential factors influencing MLH1 and PMS2 mutations. This case signifies the critical importance of vigilance in prospective diagnosis, as it can easily be misattributed to less severe, benign conditions. It also emphasizes the pressing need to refine screening guidelines to include younger individuals at risk, irrespective of family history to improve prognosis and overall patient survival. 


Unmasking CRC in the Young: MLH1/PMS2 Mutations and a Call for Early Screening

Background
While alcoholic cirrhosis typically develops over prolonged periods of excessive alcohol consumption, instances of rapid decompensation in young adults are uncommon and warrant investigation into alternative or compounding etiologies.
Case Presentation
A 23-year-old woman with a history of alcohol use disorder (consuming half a pint daily for four years), erosive gastropathy, alcoholic cirrhosis with varices, chronic anemia, thrombocytopenia, and major depressive disorder presented with escalating abdominal distention, bilateral lower extremity edema, dyspnea, pruritus, and somnolence. She ceased alcohol intake on April 7, 2025. On admission, vital signs indicated hypotension (95/58 mmHg), and physical examination revealed jaundice, scleral icterus, ascites, and suprapubic tenderness. Laboratory findings included WBC 17, Hgb 8.6, Na 130, total bilirubin 23.1 (up from 11), INR 2.6, AST 81, ALT 21, and peak ammonia at 75.

Imaging on April 9 demonstrated cirrhosis, portal hypertension, splenomegaly, extensive varices, and a right thigh hematoma. MRCP identified cholelithiasis or sludge, peritoneal thickening, and hepatic lesions. Elevated tumor markers (CA-125 226, CA 19-9 73.0) and a family history of ovarian and pancreatic cancer raised concerns for malignancy; however, transvaginal ultrasound and abdominal MRI on April 26 revealed no acute gynecologic pathology but noted gastric wall edema and moderate ascites. AFP and CEA levels were within normal limits.

Positive EBV and CMV IgM prompted HIV testing; the combo Ag/Ab test was reactive, though HIV NAAT was negative. A repeat test was ordered. Due to rapid fluid accumulation, paracentesis was performed on April 28, resulting in a MELD 3.0 score improvement from 33 to 29.
Discussion
This case underscores the necessity of a comprehensive diagnostic approach in young patients exhibiting severe liver decompensation disproportionate to their alcohol consumption history. The patient's rapid deterioration prompted evaluations for infectious, inflammatory, and oncologic causes, highlighting the importance of considering multifactorial etiologies. Multidisciplinary collaboration was crucial in avoiding diagnostic anchoring and ensuring a thorough investigation. This case contributes to clinical practice by emphasizing the need for vigilance in atypical presentations of common conditions. It may also prompt earlier or broader diagnostic evaluation in young patients with cirrhosis whose clinical course is inconsistent with known risk factors.


Atypical Rapid Decompensation in a Young Woman with Alcoholic Cirrhosis: A Diagnostic Challenge Beyond Alcohol Use


Background
Artificial intelligence–enabled medical devices (AIMDs) are increasingly present in US clinical practice. However, nearly all AIMDs are cleared through the US Food and Drug Administration (FDA) 510(k) pathway, which does not require prospective human testing and thereby leads to many devices entering the market with limited or absent clinical validation. To investigate the clinical risk of this development and identify actionable areas for regulatory safeguards, we analyzed the contributory variables and clinical consequences of all AIMD recalls in the US.
Methods
The FDA AI/ML medical device database was used to compile a cohort of 950 FDA-cleared AIMDs. We manually extracted device information from all device approval summaries and identified 60 devices that were subject to recall and extracted data on these events using the FDA recall database. The S&P Capital IQ NetAdvantage and PrivCo databases were used to analyze AIMD manufacturers based on company trading status, headquarters location, market capitalization, and acquisition history. Multivariable logistic regression (GraphPad Prism 10; 2-sided α = .05) modeled the odds of any recall, adjusting for validation status, manufacturer type, clearance year, and clinical specialty. 
Results
Of 950 FDA-cleared AIMDs, 60 (6.3%) were recalled across 182 total recall events. Of these 182 recalls, 11% have remained unresolved for >3 years and 43% of recalls occurred within the first year following FDA clearance, double the reported rate for non-AIMD 510(k) devices. Diagnostic errors were the most common recall cause (109 recalls; 935,063 units), followed by functionality delay (44 recalls; 755,647 units), physical hazards (14 recalls; 8,192 units), and biochemical hazards (13 recalls; 76,257 units). We found that AIMDs without clinical validation had more recalls per device (mean 3.4 [SD 5.1]) than those with retrospective (1.9 [SD 1.5]) or prospective (2.0 [SD 1.4]) clinical testing. Similarly, larger publicly-traded companies manufactured 53.2% of AIMDs, but were responsible for 92% of recalls and 99% of recalled units. Multivariable analysis, revealed that lack of clinical validation (odds ratio [OR], 2.8; 95% CI, 1.6-4.7) and public company status (OR, 5.9; 95% CI, 2.4-14.6) were independently associated with higher likelihood of device recall. 
Conclusion
Recalls of FDA-cleared AIMDs are uncommon, but are concentrated early after clearance and predominantly involves products without clinical validation and manufactured by large publicly traded companies. Issuing time-limited clearances that lapse without confirmatory data, heightening pre-market clinical testing requirements, and increasing post-market surveillance measures are needed for improved identification and reduction of device errors.

From Expansion to Recalls: Artificial Intelligence-Enabled Medical Devices

Background:
FLT3-ITD mutation occurs in 25–30% of acute myeloid leukemia (AML) and is associated with a poor prognosis. FLT3 inhibitors (FLT3i), such as gilteritinib and quizartinib, improve initial response rates, but relapse is common. While on-target resistance via FLT3-TKD mutations is established, emerging evidence suggests that “collateral resistance,” characterized by the outgrowth of non-FLT3 subclones, contributes significantly to therapeutic escape. This review synthesizes current data on clonal evolution under FLT3i pressure, focusing on non-FLT3 subclonal emergence.

Methods:
We conducted a comprehensive review of published studies done up to June 2025, in PubMed, Web of Science, and Scopus. Studies were included if they involved FLT3-mutated AML patients treated with FLT3 inhibitors, reported paired genomic data at diagnosis and relapse. Data on FLT3i type, resistance mechanisms, mutation spectrum, and variant allele frequency (VAF) changes were extracted from clinical trials, retrospective cohorts, and preclinical models.

Results:
In a cohort of 41 relapsed patients treated with gilteritinib, 33% developed FLT3-TKD mutations (D835, F691L), 36.6% acquired NRAS/KRAS mutations, and 5% developed BCR-ABL1 fusions. Another study found off-target RAS/MAPK pathway mutations in 30–37% of relapses, frequently co-occurring with ASXL1, RUNX1, and PTPN11 mutations. Resistance to quizartinib was driven by FLT3-TKD mutations in 33–50% of cases, yet up to 50% of relapses lacked FLT3 mutations, suggesting alternative mechanisms such as microenvironmental signaling and off-target mutations. Three reported cases of BCR-ABL1 fusion following FLT3i failure showed partial responses to combined FLT3 and ABL1 inhibition. Single-cell DNA sequencing revealed that non-FLT3 subclones, undetectable at baseline by bulk sequencing, expanded under FLT3 inhibitor pressure, demonstrating polyclonal resistance and clonal selection as key drivers of relapse. These studies consistently demonstrate that non-FLT3 resistance, particularly involving the RAS/MAPK axis, is frequent and clinically relevant following targeted therapy.

Conclusion:
Collateral resistance to FLT3 inhibitors in AML is frequently mediated by the selection of pre-existing, low-frequency non-FLT3 mutant subclones, particularly those involving the RAS/MAPK pathway. These findings emphasize the importance of comprehensive genomic profiling for diagnosis and relapse. Future therapeutic strategies should prioritize rational drug combinations targeting FLT3 and non-FLT3 pathways to overcome resistance and improve patient outcomes.


REFERENCES
1.Smith, C. C., Levis, M. J., Perl, A. E., et al. (2022). Molecular profile of FLT3-mutated relapsed/refractory patients with AML in the phase 3 ADMIRAL study of gilteritinib. Blood Advances, 6(7), 2144–2155. https://doi.org/10.1182/bloodadvances.2021006489 (Leading Journal)
2. Smith, C. C., Lin, K., Stecula, A., Sali, A., & Shah, N. P. (2015). FLT3 D835 mutations confer differential resistance to type II FLT3 inhibitors. Leukemia, 29(12), 2390–2392. https://doi.org/10.1038/leu.2015.165 (Leading Journal)
3. Tarver, T. C., Hill, J. E., Rahmat, L., et al. (2020). Gilteritinib is a clinically active FLT3 inhibitor with broad activity against FLT3 kinase domain mutations. Blood Advances, 4(3), 514–524. https://doi.org/10.1182/bloodadvances.2019000919 (Leading Journal)



Collateral Resistance in FLT3-Mutated AML: Unraveling Non-FLT3 Subclonal Emergence and Therapeutic Escape Under FLT3 Inhibitor Pressure - A Comprehensive Literature Review

Background: The compression of pre-clinical medical education from 24 to 18 months has pushed students to rely on third-party resources (TPR) for board preparation. While TPRs are effective, they are expensive and numerous. Choosing a TPR can feel overwhelming for students still adjusting to academic demands. Despite widespread use, limited data guides TPR selection. Prior studies have described usage patterns, but none have examined whether learning styles predict resource preference, and no tools currently exist to guide platform choice. We aimed to characterize current TPR use and determine whether learning style, as measured by the Barsch Learning Style Inventory (BLSI), could predict resource preference.

Methods: A cross-sectional REDCap survey was distributed to MD students (Classes of 2025–2028) at a single U.S. institution. Students ranked their top three resources for learning and reviewing material, reported reasons for using TPRs, and completed the validated BLSI. Based on their highest BLSI scoring domain, students were categorized as visual, auditory, or kinesthetic learners. Trends in resource utilization were assessed across the cohort and within each learning style using Fisher’s Exact Test with Benjamini-Hochberg correction for pairwise comparisons.

Results: Of 149 responses, 104 were included in the analysis; 45 incomplete responses were excluded. The cohort included 67 visual, 24 kinesthetic, and 13 auditory learners. Over 80% of students trialed TPRs including Sketchy, First Aid (FA), Boards and Beyond (B&B), UWorld, Anki, and Bootcamp, while only 72% trialed Institution-Provided Resources (IR). B&B (71%), Bootcamp (45%), IR (30%), and Sketchy (38%) were the most frequently selected learning resources, based on the proportion of students who included them in their top three rankings. Visual learners showed a significant preference for B&B over other learning resources (p<0.01). Auditory and kinesthetic learners also favored B&B and Bootcamp, though differences were not statistically significant. Analysis of review resources revealed no significant differences across learning styles, with UWorld, Anki, and FA consistently ranking as the top three choices. Overall, 95.5% of participants indicated they would choose a TPR over IRs if limited to one for Step 1 preparation.

Conclusion: Learning style may influence preferred TPRs, with visual learners showing a significant inclination toward B&B. While B&B and Bootcamp were broadly favored, students often trial multiple TPRs at personal expense before settling on one. A predictive tool using BLSI may help streamline TPR selection. Institutions may leverage these findings to support student decision-making and subsidize high-value resources, reducing financial waste.

Predicting Third-Party Resource Preferences Using the Barsch Learning Style Inventory

Introduction: Opill’s 2023 FDA approval for over-the-counter (OTC) sale could expand contraceptive access in the United States without age restrictions. Since approval does not ensure widespread access, we sought to evaluate Opill’s availability in New York State. 

Methods: We randomly sampled 379 of 7143 New York pharmacies from the National Provider Identification directory to estimate the proportion stocking Opill with 95% confidence. We classified pharmacies by type (independent, chain, or chain-in-retailer), location (metro or non-metro), and county-level 2024 presidential election results. Posing as 16-year-old secret shoppers, we collected on in-store availability, ordering availability, cost, and age restrictions. We performed descriptive statistical analyses and Chi-squared testing, setting significance at 5% using Stata SE Version 16.0. 

Results: In June-July 2025, 214/379 (56.5%) New York pharmacies had Opill in-store. Of those that did not, 76/165 (46.1%) could order it with a one day median delivery time. The average one month cost was $25.29. Chain pharmacies were more likely to stock Opill (76.5% vs. 52.8% chain-in-retailer vs. 46.05% independent; p<0.001). Availability did not differ by urban status or county political affiliation. Additionally, 21 (7.3%) pharmacists imposed age restrictions, 36 (9.5%) confused Opill with emergency contraception, 16 (4.2%) never heard of Opill, and 9 (2.4%) ceased stocking given low sales. 

Conclusions: Current OTC availability of Opill appears limited to approximately half of New York State pharmacies. Knowledge gaps among pharmacy staff should be addressed to maximize Opill’s public health impact.

Over-the-Counter, Out of Reach: A Secret Shopper Study of Opill Availability in New York Pharmacies


Background
Alzheimer's Disease (AD), a neurodegenerative condition causing progressive cognitive and behavioral decline, is the most prevalent dementia, accounting for roughly 70% of all cases. Its pathology is complex, influenced by genetic, lifestyle, and environmental factors. Affecting nearly seven million Americans aged 65 and older and ranking as the fifth-leading cause of death, AD mortality has risen, particularly in rural areas due to limited healthcare access. This barrier often leads to misdiagnosis or delayed AD diagnosis, worsening patient outcomes. This review examines three major AD healthcare access barriers for the rural geriatric population and proposes early preventive interventions to enhance patient quality of life.

Methods
A literature search was performed across several academic databases, including PubMed and ScienceDirect. Relevant studies included peer-reviewed articles published between the years 2020 to 2025. Key search terms included “Alzheimer’s”, “rural”, “barriers to care”, and “prevention”.

Results
Rural living presents significant healthcare access challenges for AD patients requiring specialized treatment. Primary obstacles include limited healthcare infrastructure, with many towns lacking hospitals or solely having clinics with restricted schedules. This limitation, therefore, forces patients to travel significant distances to receive medical care. Building on that point, transportation further aggravates barrier issues. This is because older adults often lack vehicles or rely on caregivers with conflicting schedules due to medical or socioeconomic challenges. Lastly, insufficient digital access remains a major barrier. Despite telemedicine expansion post-COVID-19, its utilization by the geriatric population is hampered by limited digital literacy, absent home internet, and inadequate navigation support in many rural regions.
To mitigate these disparities, several actions are crucial for AD preventive care. Firstly, promoting cognitive stimulation through senior community centers can reduce AD risk by combating isolation. Secondly, improving access to affordable, nutritious local foods is vital for low-income rural individuals, impacting cognitive health. Thirdly, improving physical exercise via expanded recreation centers or sidewalks fosters safe activity. Finally, enhancing AD education for patients and caregivers is paramount, facilitating earlier symptom recognition and diagnosis during prodromal stages, thereby improving quality of life through timely intervention.

Conclusion
AD is a complex, incurable condition, necessitating more research to optimize treatment, especially for rural populations. Key barriers, including inadequate facilities, transportation, and digital illiteracy, can be addressed through initiatives like building more rural hospitals, expanding bus routes, and offering local technology education. Through expanded research, education, advocacy, and awareness, AD prevention, early diagnosis, intervention, and management will undoubtedly improve across rural communities in the United States and beyond.


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