Emily Ann Schultz

All Publications

• Development of International Quality Measures Targeting Low-Value Care in Hand Surgery. The Journal of hand surgery Schultz, E. A., Kamal, R. N., Shapiro, L. M. 2025

  Abstract

  Low-value care, defined as care in which there is no evidence of benefit, increases the risk of harm, or adds unnecessary costs, persists in hand and upper extremity care globally. To date, there are no quality measures to measure low-value care for a global setting. We aimed to develop international quality measures that are important, feasible, usable, and scientifically acceptable for reducing low-value care in hand surgery.We performed a literature review to identify areas of potential low-value care for hand surgery. A consortium of 11 United States-based surgeons with experience in hand and upper-extremity surgery and/or quality measure development completed a modified Research and Development (RAND)/ University of California, Los Angeles (UCLA) Delphi Appropriateness process to evaluate the importance, feasibility, usability, and scientific acceptability of 10 candidate quality measures to reduce low-value hand surgical care. A modified RAND/UCLA Delphi Appropriateness process was subsequently conducted that included a panel of 20 international hand surgeons who voted on the same 10 measures using the same voting criteria. Panelist agreement or disagreement was assessed using predetermined criteria.United States and international panelists achieved agreement on the four criteria for five of the 10 measures; thus, these five measures were deemed valid. These measures include minimizing the unnecessary use of immobilization for fifth metacarpal neck fractures, postinjury imaging of distal radius fractures, perioperative antibiotics for soft tissue hand surgery, pre-operative testing, and opioid use after hand surgery. Two measures were deemed valid by the US panelists only, and two measures were deemed valid by the international panel only.United States- and international-based hand and upper-extremity surgeons achieved consensus on an international quality measure portfolio to reduce low-value care in hand surgery, which may vary in practices settings globally.These quality measures may be used to reduce low-value care in many types of health systems globally.

  View details for DOI 10.1016/j.jhsa.2024.12.010

  View details for PubMedID 39891621

• Is Area-Level Social Vulnerability Index Associated With Patient-Level Health-Related Social Needs in Hand Surgery? The Journal of the American Academy of Orthopaedic Surgeons Schultz, E. A., Zhuang, T., Shapiro, L. M., Kamal, R. N. 2025

  Abstract

  Social drivers of health (SDOH) are area-level, nonmedical factors that affect health outcomes. By contrast, health-related social needs (HRSNs) are individual patient reported and are being deployed in some payment models. SDOH are often used to broadly represent health disparities of communities through metrics, such as the Social Vulnerability Index (SVI); however, the association of area-level SVI to individual HRSNs has not been well studied in hand surgery, which has implications for addressing social risks to improve health and in quality measurement.We conducted a prospective cohort study of new patients presenting to an outpatient hand surgery clinic. Patients completed a questionnaire that included demographic information, zip code, the Accountable Health Communities HRSNs Screening Tool, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH). Following completion of the survey, zip code was used to calculate SVI. Cohen kappa coefficients (k) were calculated to measure interrater agreement between SVI and HRSNs, SVI and QuickDASH, and HRSNs and QuickDASH.We included 80 patients in the study. The most commonly reported HRSNs were safety (33, 41.25%) followed by housing (14, 17.5%) and food (11, 13.75%). Seven SVIs were represented across the cohort. No notable agreement was observed between SVI and HRSNs. In addition, no notable agreement was observed between SVI or HRSNs and QuickDASH score.Although the importance of identifying SDOH is growing, the ability of these area-level measures to accurately reflect individual HRSNs is not well understood. HRSNs may represent an opportunity for patient-centered assessments of needs and to guide resource deployment to improve outcomes for hand surgery patients.Level II prognostic study.

  View details for DOI 10.5435/JAAOS-D-24-00989

  View details for PubMedID 39841961

• MRI for Scaphoid Nonunion: Utilization Rates, Factors Associated with Utilization, and Subsequent Vascularized Bone Graft Use. The Journal of hand surgery Shapiro, L. M., Schultz, E. A., Welch, J., Zhuang, T., Kamal, R. N. 2024

  Abstract

  The use of magnetic resonance imaging (MRI) for evaluation of scaphoid nonunion may be an example of low-value imaging for the treatment of scaphoid nonunion. The purpose of this study was to investigate variation in MRI use for scaphoid nonunion, the association of MRI with a vascularized bone graft (VBG) and to develop consensus on MRI use for scaphoid nonunion.We identified patients >18 years of age who underwent scaphoid nonunion surgery between 2010 and 2019 using a claims database. Patients who had, and did not have, an MRI within 90 days prior to their diagnosis of scaphoid nonunion were included and a multivariable analysis was performed to evaluate variation in MRI and VBG use. Subsequently, a literature review was performed, and a preliminary consensus statement was developed pertaining to the routine use of MRI for scaphoid nonunion. A consortium of nine hand surgeons evaluated the importance, feasibility, usability, and scientific acceptability of the statement through a modified RAND Coroporation/University of California, Los Angeles Delphi. Panelists evaluated the statement in two voting rounds with an intervening face-to-face discussion.We identified 1,324 eligible patients with surgical repair of a scaphoid nonunion. Two hundred and sixty-three (19.9%) underwent an MRI within 90 days prior to surgery. Differences in age, insurance type, and comorbidity burden existed between patients who received MRI and those who did not. The MRI cohort was more likely to receive VBG (10.6%) compared to those without an MRI (4.7%). Panelists agreed on the voting domains of the consensus statement and therefore the statement, "There is no benefit of routine MRI/MRA in the treatment of scaphoid nonunion with or without presumed avascular necrosis," was considered valid.MRI use within 90 days of surgical repair of scaphoid nonunion varies, is associated with greater rates of VBG use, and may represent low-value imaging given the lack of sufficient evidence on this topic.As MRI use for scaphoid nonunion varies and may represent low-value imaging, a validated consensus statement may help guide the evaluation of patients with scaphoid nonunion.

  View details for DOI 10.1016/j.jhsa.2024.10.008

  View details for PubMedID 39614839

• Does Discussing Patient-reported Outcome Measures Increase Pain Self-efficacy at an Orthopaedic Visit? A Prospective, Sequential, Comparative Series. Clinical orthopaedics and related research Schultz, E. A., Gomez, G. I., Gardner, M. J., Hu, S. S., Safran, M., Amanatullah, D. F., Shapiro, L. M., Kamal, R. N. 2024

  Abstract

  Pain self-efficacy, or the ability to carry out desired activities in the presence of pain, can affect a patient's ability to function before and after orthopaedic surgery. Previous studies suggest that shared decision-making practices such as discussing patient-reported outcome measures (PROMs) can activate patients and improve their pain self-efficacy. However, the ability of PROMs to influence pain self-efficacy in patients who have undergone orthopaedic surgery has yet to be investigated.(1) Is immediately discussing the results of a PROM associated with an increase pain self-efficacy in new patients presenting to the orthopaedic surgery clinic? (2) Is there a correlation between patient resilience or patient involvement in decision-making in changes in pain self-efficacy?This was a prospective, sequential, comparative series completed between February to October 2023 at a single large tertiary referral center at a multispecialty orthopaedic clinic. Orthopaedic subspecialties included total joint arthroplasty, spine, hand, sports, and trauma. The first 64 patients underwent standard care, and the following 64 had a conversation with their orthopaedic surgeon about their PROMs during the initial intake visit. We collected scores from the Pain Self-Efficacy Questionnaire (PSEQ), Brief Resilience Scale (BRS), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function form (PF-SF10a) and data on demographic characteristics before the visit. The PSEQ is a validated PROM used to measure pain self-efficacy, while the BRS measures the ability of patients to recover from stress, and the PROMIS PF-SF10a is used to assess overall physical function. PROMs have been utilized frequently for their ability to report the real-time physical and psychological well-being of patients. In the standard care group, the PROMIS PF-SF10a score was not discussed with the patient. In the PROMs group, the physician discussed the PROMIS PF-SF10a score using a script that gave context to the patient's score. Additional conversation about the patient's score was permitted but not required for all patients. Scores from the Observing Patient Involvement in Decision Making (OPTION-5) instrument were recorded during the visit as a measure of patient involvement in clinical decision-making. After the visit, both groups completed the PSEQ. The primary outcome was change in the PSEQ. Change in pain self-efficacy was recorded as greater or less than the minimum clinically important difference, previously defined at 8.5 points for the PSEQ [10]. The secondary outcomes were correlation between PSEQ change and the BRS or OPTION-5.Between the PROMs and standard care groups, there was no difference in the change in PSEQ scores from before the visit to after (mean ± SD change in control 4 ± 10 versus change in PROMs group 3 ± 7, mean difference 1 [95% confidence interval (CI) -2.0 to 4.0]; p = 0.29). Fifty-six percent (36 of 64) of patients in the standard care group demonstrated an increase in pain self-efficacy (of whom 22% [14 of 64] had clinically important improvements), and 59% (38 of 64) of patients in the PROMs group demonstrated an increase in pain self-efficacy (of whom 19% [12 of 64] had clinically important improvements). In the control group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.13 [95% CI -0.36 to 0.12]; p = 0.30) or patient involvement in decision-making (OPTION-5 r = 0.003 [95% CI -0.24 to 0.25]; p = 0.98). Similarly, in the PROMs group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.10 [95% CI -0.33 to 0.16]; p = 0.45) or patient involvement in decision-making (OPTION-5 r = -0.02 [95% CI -0.26 to 0.23]; p = 0.88).Discussing PROMs results (PROMIS PF-SF10a) at the point of care did not increase pain self-efficacy during one visit. Therefore, surgeons do not need to discuss pain self-efficacy PROM scores in order to influence patient pain self-efficacy. While PROMs remain valuable tools for assessing patient outcomes, further work may assess whether the collection of PROMs itself may increase pain self-efficacy or whether longitudinal discussion of PROMs with patients changes pain self-efficacy.Level II, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000003325

  View details for PubMedID 39589313

• Quality Measures Addressing Orthopaedic Surgery in Ambulatory Surgery Centers: A Systematic Review Snyder, E., Schultz, E. A., Shapiro, L. M., Kamal, R. N. LIPPINCOTT WILLIAMS & WILKINS. 2024: S333-S334

  View details for Web of Science ID 001348680702141

• Surgeon Alignment With Clinical Practice Guidelines: A Qualitative Analysis of Treatment of Distal Radius Fractures. Hand (New York, N.Y.) Schultz, E. A., Eppler, S. L., Shapiro, L. M., Kamal, R. N. 2024: 15589447241277843

  Abstract

  Clinical practice guidelines (CPGs) are developed to guide physicians in providing consistent high-quality care. Despite availability of evidence-based guidelines for the treatment of distal radius fractures, prior work suggests many patients receive treatment that is misaligned with the CPG. We sought to explore barriers and facilitators of guideline-aligned care for distal radius fractures.We conducted semistructured interviews of a purposive sample of surgeons who treat distal radius fractures. Our interview guide was based on the Theoretical Domains Framework (TDF). Interviews were transcribed and coded using a deductive analytical approach within the 14 TDF domains. Belief statements underlying similar codes were developed to describe barriers and facilitators of guideline-aligned care. A content analysis was performed to count the frequency of each TDF domain.We interviewed 14 surgeons. The most common TDF domains were beliefs about consequences (110), knowledge (49), and social influences (29). Belief statements representative of barriers of concordance to the CPGs included, "I am more likely to deviate from the CPGs when the CPGs differ from my professional opinion," which was coded under beliefs about consequences. Similar belief statements were created for each theme within TDF domains.Decision-making for patients with distal radius fractures is driven by beliefs about consequences, knowledge, and social influences. Strategies to address these beliefs in other fields such as including patient factors in a further structured shared decision-making process, developing implementation toolkits as part of the CPG development process, and implementing payment programs may improve CPG alignment.

  View details for DOI 10.1177/15589447241277843

  View details for PubMedID 39370690

• Health Numeracy Is Associated With a Patient's Ability to Interpret Patient-Reported Outcome Measures Data. Orthopedics Schultz, E. A., Eppler, S. L., Gardner, M., Hu, S. S., Chou, L., Safran, M., Amanatullah, D. F., Abrams, G. D., Shapiro, L. M., Kamal, R. N. 2024: 1-6

  Abstract

  Patient-reported outcome measures (PROMs) were originally developed as research tools; however, there is increasing interest in using PROMs to inform clinical care. Prior work has shown the benefits of implementing PROMs at the point of care, but a patient's health numeracy (their ability to understand and work with numbers) may affect their ability to interpret PROM results.We recruited patients presenting to an outpatient orthopedic clinic. Forty-nine patients completed a survey that included demographic information, the short-form General Health Numeracy Test, and accuracy questions about four PROM displays (bar graph, table, line graph, pictograph) that indicated the same PROM results.Patients with higher health numeracy answered all display accuracy questions correctly (P=.016). Patients who preferred using the table were more likely to answer display accuracy questions incorrectly (odds ratio, 0.013, P=.024). The two most frequently preferred PROM formats were bar graphs and tables, and most patients preferred to learn about their PROM function scores via a combination of displays and verbal discussions.Patient health numeracy is associated with the ability to correctly interpret visual displays of PROMs. Implementation of PROMs at point of care currently does not account for health numeracy. Efforts to account for health numeracy when using PROMs at point of care may improve the efficacy of using PROMs to improve outcomes in orthopedic surgery. [Orthopedics. 202x;4x(x):xx-xx.].

  View details for DOI 10.3928/01477447-20240718-04

  View details for PubMedID 39073043

• Training Background and Demographic Characteristics of Primary Care Team Physicians in Professional Sports. Orthopaedic journal of sports medicine Schultz, E. A., Durtschi, M. S., Oakes, K. G., Kussman, A., Hwang, C. E. 2024; 12 (4): 23259671241242412

  Abstract

  Previous studies have shown that most professional head and orthopaedic team physicians are men, and most orthopaedic team physicians are fellowship-trained. It is unknown whether this holds true for primary care team physicians.To evaluate the residency and fellowship training background as well as the demographic characteristics of primary care team physicians in professional sports.Cross-sectional study.Publicly available information was used to determine the lead and supporting primary care team physicians for every US-based team in Major League Baseball, Major League Soccer, National Basketball Association, National Football League, National Hockey League, National Women's Soccer League, and Women's National Basketball Association. Data regarding training background and sex were obtained using internet-based sources.We identified 310 primary care team physicians from all 165 US-based teams in the 7 leagues included in the study. Female physicians comprised 11.5% (19/165) of the lead primary care team physicians and 14.2% (44/310) of all primary care team physicians. Overall, 66.7% (110/165) of lead primary care team physicians and 75.5% (234/310) of all primary care team physicians were sports medicine fellowship-trained. There was a higher proportion of female (37.5%) and fellowship-trained (93.8%) physicians in women's professional sports leagues. Most primary care team physicians (244/310 [78.7%]) were trained in family medicine or internal medicine.Women constituted a small minority of primary care team physicians in professional sports. Most primary care team physicians were residency trained in family medicine or internal medicine and were sports medicine fellowship-trained. The proportion of female and fellowship-trained primary care team physicians was highest in the National Women's Soccer League and the Women's National Basketball Association.

  View details for DOI 10.1177/23259671241242412

  View details for PubMedID 38680217

  View details for PubMedCentralID PMC11047226

• The Safety of the Volar Intraarticular Extended Window (VIEW) Approach for Intra-articular Distal Radius Fractures. Hand (New York, N.Y.) Kamal, R. N., Gomez, G. I., Schultz, E. A., Shapiro, L. M. 2023: 15589447231210926

  Abstract

  A novel volar approach to intra-articular distal radius fractures has been introduced for treatment of intra-articular distal radius fractures, in which volar extrinsic ligaments are released to create a volar window into the radiocarpal joint (Volar Intraarticular Extended Window [VIEW] approach). Our purpose was to evaluate the safety of VIEW approach for treatment of intra-articular distal radius fractures.A retrospective chart review was performed for 13 patients with intra-articular distal radius fractures treated operatively with the VIEW surgical technique using an intra-articular window in the volar capsule to aid in reduction and fixation. Postoperative radiographs were reviewed to assess for ulnocarpal translocation by assessing lunate uncovering and radial-carpal distance.Thirteen patients were treated with the VIEW approach with mean follow-up of 28 weeks (range, 7-67 weeks; SD, 18 weeks). The mean postoperative lunate uncovering was 34.6% (SD, 7.7%) and mean radial-carpal distance was 4.6 mm (SD, 1.5 mm). Postoperatively, mean intra-articular step-off was 0.9 mm (SD, 1.2 mm) and mean intra-articular gap was 1.2 mm (SD, 1.0 mm). No patients reported clinical symptoms of wrist instability.Using the VIEW approach during a volar approach to intra-articular distal radius fractures is safe and does not lead to carpal instability. Surgeons can consider using the approach when direct visualization of the articular surface may be beneficial for reduction or fixation.Therapeutic IV.

  View details for DOI 10.1177/15589447231210926

  View details for PubMedID 38006231

• Is Outpatient Spine Surgery Associated with New, Persistent Opioid Use in Opioid-Naïve Patients? A Retrospective National Claims Database Analysis. The spine journal : official journal of the North American Spine Society Schultz, E., Zhuang, T., Shapiro, L. M., Hu, S. S., Kamal, R. N. 2023

  Abstract

  Although spine procedures have historically been performed inpatient, there has been a recent shift to the outpatient setting for selected cases due to increased patient satisfaction and reduced cost. Effective postoperative pain management while limiting over-prescribing of opioids, which may lead to persistent opioid use, is critical to performing spine surgery in the outpatient setting.To assess if there is an increased risk for new, persistent opioid use between inpatient and outpatient spine procedures.Retrospective analysis using national administrative claims database.390,049 opioid-naïve patients with a perioperative opioid prescription who underwent an inpatient or outpatient spine surgery.Patients with perioperative opioid prescriptions who filled ≥ 1 opioid prescription between 90- and 180-days following surgery were defined as new, persistent opioid users.We utilized a claims database to identify opioid-naïve patients who underwent lumbar or cervical fusion, total disc arthroplasty, or decompression procedures. We constructed a multivariable logistic regression to evaluate the association between inpatient versus outpatient surgery and the development of new, persistent opioid use while adjusting for several patient factors.19,205 (11.7%) inpatient and 18,546 (8.2%) outpatient patients developed new, persistent opioid use. Outpatient lumbar and cervical spine surgery patients were significantly less likely to develop new, persistent opioid use following surgery compared to inpatient spine surgery patients (OR = 0.71 [95% confidence interval (CI): 0.69, 0.73], p < 0.001). Average morphine milligram equivalents (MMEs) (inpatient = 1,476 MME +/- 22.7, outpatient = 1,072 MME +/- 18.5, p < 0.001) and average MMEs per day (inpatient = 91.6 MME +/- 0.32, outpatient = 77.7 MME +/- 0.28, p < 0.001) were lower in the outpatient cohort compared to the inpatient.Our results support the shift from inpatient to outpatient spine procedures, as outpatient procedures were not associated with an increased risk for new, persistent opioid use. As more patients become candidates for outpatient spine surgery, predictors of new, persistent opioid use should be considered during risk stratification.Level III Prognostic Study.We utilized a national administrative claims database to identify opioid-naïve patients who underwent common spine procedures. Outpatient lumbar and cervical spine surgery patients were significantly less likely to be new, persistent opioid users following surgery compared to inpatient spine surgery patients. Our results support the shift to outpatient spine procedures.

  View details for DOI 10.1016/j.spinee.2023.06.391

  View details for PubMedID 37355048

• Has the Use of Electrodiagnostic Studies for Carpal Tunnel Syndrome Changed After the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline? The Journal of hand surgery Zhuang, T., Shapiro, L. M., Schultz, E. A., Truong, N. M., Harris, A. H., Kamal, R. N. 2022

  Abstract

  PURPOSE: A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG.METHODS: Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release.RESULTS: Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (-11.50 per 1,000 patients [95% CI, -1.47 to-0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97-2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by-23.57 per 1,000 patients (95% CI,-37.72 to-9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG.CONCLUSIONS: The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS.CLINICAL RELEVANCE: Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.

  View details for DOI 10.1016/j.jhsa.2022.09.019

  View details for PubMedID 36460552

• Comparison of SARS-CoV-2 Test Positivity in NCAA Division I Student Athletes vs Nonathletes at 12 Institutions. JAMA network open Schultz, E. A., Kussman, A., Jerome, A., Abrams, G. D., Hwang, C. E. 2022; 5 (2): e2147805

  Abstract

  Importance: The COVID-19 pandemic initially led to the abrupt shutdown of collegiate athletics until guidelines were established for a safe return to play for student athletes. Currently, no literature exists that examines the difference in SARS-CoV-2 test positivity between student athletes and nonathletes at universities across the country.Objective: To identify the difference in risk of COVID-19 infection between student athlete and nonathlete student populations and evaluate the hypothesis that student athletes may display increased SARS-CoV-2 test positivity associated with increased travel, competition, and testing compared with nonathletes at their respective universities.Design, Setting, and Participants: In this cross-sectional analysis, a search of publicly available official university COVID-19 dashboards and press releases was performed for all 65 Power 5 National Collegiate Athletic Association (NCAA) Division I institutions during the 2020 to 2021 academic year. Data were analyzed at the conclusion of the academic year. Schools that released at least 4 months of testing data, including the fall 2020 football season, for student athletes and nonathlete students were included in the analysis. Power 5 NCAA Division I student athletes and their nonathlete student counterparts were included in the analysis.Exposure: Designation as a varsity student athlete.Main Outcomes and Measures: The main outcome was SARS-CoV-2 test positivity for student athletes and nonathlete students at the included institutions for the 2020 to 2021 academic year, measured as a relative risk for student athletes.Results: Among 12 schools with sufficient data available included in the final analysis, 555 372 student athlete tests and 3 482 845 nonathlete student tests were performed. There were 9 schools with decreased test positivity in student athletes compared with nonathlete students (University of Arkansas: 0.01% vs 3.52%; University of Minnesota: 0.63% vs 5.96%; Penn State University: 0.74% vs 6.58%; Clemson University: 0.40% vs 1.88%; University of Louisville: 0.75% vs 3.05%; Purdue University: 0.79% vs 2.97%; University of Michigan: 0.40% vs 1.12%; University of Illinois: 0.17% vs 0.40%; University of Virginia: 0.64% vs 1.04%) (P<.001 for each). The median (range) test positivity in these 9 schools was 0.46% (0.01%-0.79%) for student athletes and 1.04% (0.40%-6.58%) for nonathlete students. In 1 school, test positivity was increased in the student athlete group (Stanford University: 0.20% vs 0.05%; P<.001). Overall, there were 2425 positive tests (0.44%) among student athletes and 30 567 positive tests (0.88%) among nonathlete students, for a relative risk of 0.50 (95% CI, 0.48-0.52; P<.001). There was no statistically significant difference in student athlete test positivity between included schools; however, test positivity among nonathlete students varied considerably between institutions, ranging from 133 of 271 862 tests (0.05%) at Stanford University to 2129 of 32 336 tests (6.58%) at Penn State University.Conclusions and Relevance: This study found that in the setting of SARS-CoV-2 transmission mitigation protocols implemented by the NCAA, participation in intercollegiate athletics was not associated with increased SARS-CoV-2 test positivity. This finding suggests that collegiate athletics may be held without an associated increased risk of infection among student athletes.

  View details for DOI 10.1001/jamanetworkopen.2021.47805

  View details for PubMedID 35138397

• The influence of vector-borne disease on human history: socio-ecological mechanisms. Ecology letters Athni, T. S., Shocket, M. S., Couper, L. I., Nova, N., Caldwell, I. R., Caldwell, J. M., Childress, J. N., Childs, M. L., De Leo, G. A., Kirk, D. G., MacDonald, A. J., Olivarius, K., Pickel, D. G., Roberts, S. O., Winokur, O. C., Young, H. S., Cheng, J., Grant, E. A., Kurzner, P. M., Kyaw, S., Lin, B. J., Lopez, R. C., Massihpour, D. S., Olsen, E. C., Roache, M., Ruiz, A., Schultz, E. A., Shafat, M., Spencer, R. L., Bharti, N., Mordecai, E. A. 2021

  Abstract

  Vector-borne diseases (VBDs) are embedded within complex socio-ecological systems. While research has traditionally focused on the direct effects of VBDs on human morbidity and mortality, it is increasingly clear that their impacts are much more pervasive. VBDs are dynamically linked to feedbacks between environmental conditions, vector ecology, disease burden, and societal responses that drive transmission. As a result, VBDs have had profound influence on human history. Mechanisms include: (1) killing or debilitating large numbers of people, with demographic and population-level impacts; (2) differentially affecting populations based on prior history of disease exposure, immunity, and resistance; (3) being weaponised to promote or justify hierarchies of power, colonialism, racism, classism and sexism; (4) catalysing changes in ideas, institutions, infrastructure, technologies and social practices in efforts to control disease outbreaks; and (5) changing human relationships with the land and environment. We use historical and archaeological evidence interpreted through an ecological lens to illustrate how VBDs have shaped society and culture, focusing on case studies from four pertinent VBDs: plague, malaria, yellow fever and trypanosomiasis. By comparing across diseases, time periods and geographies, we highlight the enormous scope and variety of mechanisms by which VBDs have influenced human history.

  View details for DOI 10.1111/ele.13675

  View details for PubMedID 33501751