Статті в журналах з теми "Pre-competitive preparation phase (Pc2P)"

Abstract Abstract 150 Background: Historically, bone marrow transplantation (BMT) in class 3 thalassemia patients has been associated with a significant risk of graft failure and transplant-related mortality leading to lower disease-free survival. Our initial study showed that class 3 patients treated with a new treatment protocol (Pc 26) had an improved survival and decreased rejection rates compared with previous protocols (Blood 2004;104:1201). An interim analysis of our subsequent experience with BMT in class 3 patients treated with Pc26 showed an increased rejection rate which has prompted us to modify the protocol to overcome this complication. Since February 2007 we have been using the modified Pc26 (Pc26m) in class 3 patients. Patients and Methods: Between June 2004 and July 2011 a total of 45 class 3 patients with median age of 10 years (range, 5–16) were treated: 26 patients with original (Pc26) and 19 patients with modified protocol (Pc26m). The two groups were well balanced in respect to baseline demographic and clinical characteristics. Patients had severe iron overload with median serum ferritin and liver iron concentration of 2626 ng/mL (range, 777–10222) and 20,8 mg/g dry weight (range, 5–40.7), respectively. Median liver fibrosis score was 2 (range, 1–5). There were 5 patients with HCV, and 1 with hepatitis B virus (HB Ag-positive) at the time of transplantation. The median number of packed RBC transfusions was 140 units (range, 25–307). The Pc26m consisted of pre-conditioning and conditioning phases. This novel treatment regimen involved an intensified preparation with 3 mg/kg of azathioprine and 30 mg/kg hydroxyurea daily from day -45 from the transplant, fludarabine 30 mg/m2 from day -16 through day -12, followed by the administration of weight based busilvex (since 2006), Thiotepa 10 mg/kg/day and CY 160 mg/kg total dose. GVHD prophylaxis consisted of CSA, low-dose methylprednisolone, and a modified “short course” of methotrexate (MTX). Results: Four of 26 patients treated with Pc26 and none of 19 patients treated with Pc26m had graft failure. The median time of neutrophil recovery (ANC>500 ×109/L) and platelet recovery (>20 ×109/L) were similar in both group of patients. Transplant outcomes are shown in Table 1. Overall treatment protocol was well tolerated without any significant toxicity. None of the patients had grade 4 toxicity. Most frequent grade 3 toxicity was AST and ALT elevations. Five patients, 3 treated with Pc26 and 2 with Pc26m had grade 2 hemorrhagic cystitis. One patient in each group had moderate liver VOD resolved with supportive care. Two patients in Pc26 group and one in the Pc26m group had pneumonia. There were 3 patients with bacteremia: 2 in Pc26 and one in Pc26m treated patients. The incidence of CMV reactivation was similar in both group. Conclusion: This study shows that the modified treatment protocol for class 3 thalassemia patients is highly effective in terms of graft failure leading to a high DFS rate which is comparable to those obtained in class 1 and class 2 patients. It also suggests that this intensified preparative regimen aimed at reducing a large disease burden and increasing immunosuppression over time thus avoiding unacceptable peritransplant drug toxicity is essential for minimizing graft failure in these high-risk patients. Disclosure: No relevant conflict of interest to declare. Disclosures: No relevant conflicts of interest to declare.

Working in the discipline of eventing (the triathlon of equestrian sport), the present study aims to extend current literature on the use of psychological skills within equestrian sports, by understanding and identifying differences in levels of self-confidence and competitive anxiety. Each eventing phase (dressage, show-jumping and cross-country) was considered and its impact on anxiety and self-confidence analysed. Level of competition was considered a covariate and its effect on specific eventing phases and any associated influence on anxiety and self-confidence within eventing phase was analysed. An experimental, 3×3 factorial, within-subjects design was used. 57 participants (52 female and 5 male; 18 professional, 36 amateur and 3 undefined) completed the Revised Competitive Sport Anxiety Inventory 2 (CSAI-2R), a 17-item questionnaire measuring anxiety and self-confidence. Descriptive statistics identified the show-jumping phase had the largest impact on rider somatic anxiety (SA) and cognitive anxiety (CA). The cross-country phase had the highest self-confidence mean score. Spearman’s rank correlations showed both SA and CA were debilitative for all competition levels. Both SA and CA were found to be more debilitating in the show-jumping phase when self-confidence was low. MANCOVA analysis showed that eventing phase had significant effect on anxiety and self-confidence when controlling for level of competition. Dependent on the eventing phase riders are competing in, they experience different levels of arousal and self-confidence. When SA and CA are a debilitative source of anxiety, this could result in rider muscle tension which is not conducive to effective horse-rider communication. Coaches or sports psychologists should consider how to help riders manage their anxiety levels in relation to the competition phase, with the intention of enhancing self-confidence and enabling facilitative SA and CA in preparation for eventing performance.

The present paper aimed to systematically review case studies on physique athletes to evaluate longitudinal changes in measures of body composition, neuromuscular performance, chronic hormonal levels, physiological adaptations, and psychometric outcomes during pre-contest preparation. We included studies that (1) were classified as case studies involving physique athletes during the pre-contest phase of their competitive cycle; (2) involved adults (18+ years of age) as participants; (3) were published in an English-language peer-reviewed journal; (4) had a pre-contest duration of at least 3 months; (5) reported changes across contest preparation relating to measures of body composition (fat mass, lean mass, and bone mineral density), neuromuscular performance (strength and power), chronic hormonal levels (testosterone, estrogen, cortisol, leptin, and ghrelin), physiological adaptations (maximal aerobic capacity, resting energy expenditure, heart rate, blood pressure, menstrual function, and sleep quality), and/or psychometric outcomes (mood states and food desire). Our review ultimately included 11 case studies comprising 15 ostensibly drug-free athletes (male = 8, female = 7) who competed in various physique-oriented divisions including bodybuilding, figure, and bikini. The results indicated marked alterations across the array of analyzed outcomes, sometimes with high inter-individual variability and divergent sex-specific responses. The complexities and implications of these findings are discussed herein.

Success in competition is ensured by long-term preparation, but direct pre-competition training (DPT) is of fundamental importance, with the help of which athletes must bring themselves to a state of high or the highest working capacity. Modern views on the essence and construction of preliminary training stage most intensively began to be formed since the 1960s. The reason for this was the appearance of such fundamental projects, such as "Periodization of sports training" by L.P. Matveva, "The current system of sports training" by N.G. Ozolina, "The coach of athletics trainer" ed. L.S. Khomenkovoi. The success in competitions is provided by long-term training, but fundamental importance has a direct pre-competition training (DPT), by which athletes should lead themselves to a state of high or the highest efficiency. If the goal of competition is only of training or control nature and athlete is not eager to achieve a high result, then DPT is not necessary before the starts. Such a combination of the process of training and participation in competitions may occur in the first competitions at the beginning of the competitive period. However, when there is a participating in high-level competitions or even more in the culminating competitions, in such an event, DPT is essential. Mistakes in the building of the phase of the DPT are often the reason not only for an unsuccessful speech in the main competition, but it is also the reason for a slowed down growth of achievements and even deterioration of them. All training of an athlete can be considered successful if he shows the best result in the crucial competition with a significant progress in his accomplishments.

The paper presents results of research on the effective ways and means for tillage and seeding in the cultivation of crops in drought weather conditions. In order to improve the treatment quality, moisture-accumulating capacity and water saving of the soil in cropping technology with minimum tillage, including its final (finish) preparation for sowing with lower power consumption, we proposed new tillage methods. The first method involves post-harvest surface moisture-challenging loosening the stubble to a depth of 3-5 cm, the main non-recourse autumn moisture-absorbing loosening to a depth of 20-30 cm, deep moisture-accumulating Diesel hoeing to a depth of 40-65 cm, the spring surface moisture-closing loosening to a depth of 4-5 cm and moisture-mulching pre-sowing tillage to a depth of 4-5 cm with a seal seed bed and combing the weeds in the stage of “white thread”. The second method comprises the moisture-accumulating phase, which is performed in the autumn, when in the soil a vertical slit with a controllable pitch was made by spade working units and placing them in a staggered manner. Then we perform a second spring moisture-saving phase by solid surface loosening and mulching with rotary tools with working units to a depth of seeding. So that to implement the proposed methods the authors developed a set of tillage and seeding equipment (69 types of devices, 30 types of working units, 35 types of plug-in modules). Their production was mastered. The developed machines provide higher yields by 5 kg per hectare, reduce energy and labor costs up to 50%, have a competitive advantage over domestic and foreign counterparts.

Purpose. To investigate and theoretically substantiate methods of increasing the sowing and productivity properties of seeds of perennial legumes and, on their basis, develop new and improve existing resource-saving, competitive growing technologies due to the use of mineral, fast-acting limestone fertilizers, seed inoculation with bacterial preparations based on various strains of nitrogen-fixing microorganisms and foliar feeding during the growing season with biostimulants and anti-stressors in order to expand economically valuable field and meadow grass stands on degraded natural pastures. Methods. Field, laboratory, visual, measuring, weight, quantitative, test sheaf method, mathematical, statistical. Results. Agrobiological bases for the formation of fruiting elements of perennial leguminous grasses with high productivity and sowing properties have been developed. They imply seed inoculation with the bacterial preparation Rhizobophyt 0.15 l/ha and foliar fertilizing with anti-stressor in the phase of stemming and budding of grasses on the ground of the basic fertilizer for cover crop (N30P60-90K60-90) in combination with a fast-acting limestone fertilizer (Ca(OH)2 – slaked lime – 1.2 t/ha) 0.5 norms for hydrolytic acidity. This contributed to the formation of the maximum seed yield of alfalfa – 0.29-0.30 t/ha, meadow clover – 0.47-0.49 t/ha, hybrid clover – 0.30-0.31 t/ha, deer vetch – 0.45-0.47 t/ha. Conclusions. For the successful seed production of new high-yielding varieties of perennial leguminous grasses with high sowing and productive properties, a mandatory measure is, against the background of the main fertilization with mineral and fast-acting limestone fertilizers for cover crops, the pre-sowing treatment of seeds with the bacterial preparation Rhizobophyt and foliar fertilizing with the anti-stressor Agrohumat, which contributed on average, over the years of research, to increase seed productivity by 21-57%.

“Oxygen intake”, “Hypoxia”, “Respiratory muscles training”: are very well known terms in now-a-day sports. That is why the goal of the research is to investigate the effects of the lack of oxygen on an organism’s functionality in the low season preparation term within the cycling stage of triathlon. Nine healthy active triathletes (males n=9), age (20 ± 7 years), competitive at national and international level, were trained in the equal conditions using Spinning bikes in the same room (22 °C ± 2.4 °C and 82 ± 4 % RH), at the same time, at the same cadence (100 revolutions ± 5 rev.) and performing the same exercises. All participants had 4 monocycles pre-experimental preparation (PP). Followed by 12 monocycles (hypoxia training – HT) as a part of a monthly microcycle. During a 60 min session one group was using Ultrabreathe, another group was using the Elevation Mask 2.0 and the last group didn’t use any device performing as a control group. After another 4 monocycles for recovery (R). Data was collected at the end of each phase-PP (4 monocycles in one week), in the middle and at the end of phase-HT (8-monocycles using Elevation Mask 2.0 and Ultrabreathe devices) and the end of phase-R (4-monocycles with no respiration effort). Maximal oxygen consumption (VO2max), Lactate (LA), cadence power (W) and heart rate (HR) was recorded and collected as part of the research. All were measured in laboratory conditions using KORR CardioCoach gas analyzing system for VO2max, cadence power was measured by the Monark LC4R ergometer bike, whereas blood samples were collected for lactate using the COBAS Accutrend Plus device, heart rate data was measured by the POLAR H7 heart rate belts and POLAR Power Flow system. The performances expressed changes in all four parameters on all stages of the experiment. Maximal oxygen consumption showed an increase in two groups who were using the respiratory depression devices after 8 monocycles –by 4,35 and 3,01% respectively, and by the end of the experiment the total difference was - 3,74 and 0,82 % respectively. Improvements were also defined in the level of increase in lactate and maximum cadence power. There was a power increase in the two groups who were using the respiratory depression devices after 8 monocycles - 3,92 and 1,57% respectively, and by the end of experiment the total difference was - 3,57 and 0,87 % respectively. All this data shows us the positive effects of hypoxial training.

Abstract Abstract 2266 Betrixaban is a once daily oral Factor Xa inhibitor being investigated in a Phase 3 clinical trial to prevent venous thromboembolism in acute medically ill patients (APEX Study). Mass balance, metabolite profile and interaction with major CYP enzymes were evaluated in this study. Portola study 06–005 was an open-label, single-dose, mass-balance and metabolic profiling study using 14C-labeled betrixaban in 5 healthy male volunteers. Each subject received a single oral solution containing 40 mg of betrixaban labeled with 100 μCi of 14C. Blood samples were taken serially over a 168-hour interval. Urine samples and fecal samples were collected during the 7–14 day confinement period. Subjects were discharged from the unit when at least one of the following criteria were met: 90% of the radioactivity was recovered in urine and feces, daily excreted radioactivity was 1% or less of administered dose on two consecutive days, or subject reached 336 hours (14 days) post dose. The plasma concentration equivalents of total radioactivity increased rapidly following dosing with a mean peak of 31.69 ng eq/mL occurring at 3.5 hours post-dose. AUC and half-life could not be calculated as radioactivity in plasma could only be detected up to 6 hours post dose. Terminal elimination half life determined in other clinical pharmacology studies was 37 hours. Total radioactivity recovered from urine and feces was approximately 96% (range 92% to 99%), with the majority of 14C recovery in feces (82% to 89% of the dose). The 14C dose recovered in urine, composed of betrixaban and inactive metabolites, ranged from 6% to 13%. The metabolic profile of betrixaban was determined in plasma, urine and feces. Unchanged betrixaban was the predominant component found in human plasma and excreta, accounting for 85.3% of the dose excreted in urine and feces. The major biotransformation pathway for betrixaban was hydrolysis to form PRT062802 and PRT062803, a non-14C labeled metabolite (Figure 1). PRT062803 can be demethylated to form PRT062799 or hydroxylated to form PRT062982. PRT062982 is further conjugated with sulfate to form PRT063069. Both PRT062802 and PRT063069 were major circulating metabolites in human plasma with AUC of 34% and 24% that of betrixaban, respectively. PRT062802 was the only prominent metabolite detected in human urine and feces. In addition to hydrolysis metabolites, two CYP-mediated metabolites, O-desmethyl betrixaban (PRT058326) and N-desmethyl betrixaban (PRT054156), were observed in plasma at trace levels (AUC of each was <1% that of betrixaban). Trace levels of PRT058326 was also observed in urine and feces. Both PRT062802 and PRT063069 were inactive (IC50 for fXa inhibition >10 μM). PRT058326 and PRT054156 have an IC50 for fXa inhibition of approximately 5 nM compared to betrixaban Ki of 0.117 pM. Interaction of betrixaban with CYP enzymes was studied in vitro. CYP inhibition potential was evaluated in human liver microsomes with or without 30 minute pre-incubation of betrixaban. Selective probe substrates were used to monitor CYP activities, i.e. phenacetin for 1A2, tolbutamide for 2C9, S-mephenytoin for 2C19, dextromethorphan for 2D6, and testosterone and midazolam for 3A4. Betrixaban had IC50 > 80 μM for CYP1A2, 2C9, 2D6 and 3A4 for both competitive and time-dependent inhibition. IC50 for 2C19 were 43 and 88 μM for competitive and time-dependent inhibition, respectively. The CYP inhibition IC50's are much higher than the betrixaban therapeutic concentration of 50 nM. CYP induction by betrixaban was also studied using cryopreserved human hepatocytes (n=3). Betrixaban at 1, 10 and 25 μM were incubated in hepatocyte preparation for 48 hours. The activities for CYP1A2, CYP2C9, CYP2C19, and CYP3A4 were determined by measuring the formation of metabolites of the probe substrates similar to those used in the CYP inhibition study. CYP2C19 activities were not quantifiable in all three donors; therefore, induction for this CYP isoform could not be assessed. Betrixaban did not induce the activities of CYP1A2, CYP2C9, and CYP3A4. These results demonstrated that betrixaban was mainly excreted as the unchanged drug most likely via biliary secretion. Renal excretion and metabolism were minor elimination pathways. Betrixaban is unlikely to have drug-drug interactions with CYP-substrate, inducer, or inhibitor drugs. Disclosures: Hutchaleelaha: Portola pharmaceuticals: Employment. Ye:Portola Pharmaceuticals: Employment. Song:Portola Pharmaceuticals: Employment. Lorenz:Portola Pharmaceuticals: Employment. Gretler:Portola Pharmaceuticals: Equity Ownership. Lambing:Portola Pharmaceuticals: Employment.

Abstract Background We examined the effect of the 2000-m ergometer test on gut injury in competitive elite rowers in two different training phases. Given that inflammatory markers during the competitive phase are higher, we hypothesise that markers of intestinal injury are also more elevated during that phase. Methods We performed this study during the preparatory phase (Test I) and competitive phase (Test II) of annual training. We included 10 competitive elite rowers, members of the Polish Rowing Team, in the study after applying the inclusion/exclusion criteria. The participants performed a 2000-m ergometer test during both phases (Tests I and II). We collected blood samples before the test, immediately after the test and after 1 h of recovery. We measured the levels of interleukin 6 (IL-6), intestinal fatty acid binding protein (I-FABP), lipopolysaccharide (LPS), lipopolysaccharide-binding protein (LBP), and zonulin. Results There were no significant changes over time in Test I and Test II in the gut integrity markers. There were significantly lower I-FABP and IL-6 levels after the test for Test II compared with Test I. The pre-test LPS level was significantly lower for Test II compared with Test I. The pre-test LBP and zonulin levels were numerically lower in Test II, but the differences were not significant. Conclusions The 2000-m ergometer test showed no influence on gut integrity markers. However, there were differences in the response to exercise between Tests I and II. The lower level of gut injury markers after extreme exercise tests carried out during the preparation period may be the result of adaptive mechanisms and could indicate that rationally conducted training significantly decreases intestinal injury.

AbstractKesterite Cu2ZnSn(S, Se)4 is considered one of the most competitive photovoltaic materials due to its earth-abundant and nontoxic constituent elements, environmental friendliness, and high stability. However, the preparation of high-quality Kesterite absorbers for photovoltaics is still challenging for the uncontrollability and complexity of selenization reactions between metal element precursors and selenium. In this study, we propose a solid-liquid/solid-gas (solid precursor and liquid/vapor Se) synergistic reaction strategy to precisely control the selenization process. By pre-depositing excess liquid selenium, we provide the high chemical potential of selenium to facilitate the direct and rapid formation of the Kesterite phase. The further optimization of selenium condensation and subsequent volatilization enables the efficient removal of organic compounds and thus improves charge transport in the absorber film. As a result, we achieve high-performance Kesterite solar cells with total-area efficiency of 13.6% (certified at 13.44%) and 1.09 cm2-area efficiency of 12.0% (certified at 12.1%).

ABSTRACT Introduction As college basketball continues to develop, more and more college students are joining the sport, and the resulting sports injuries have also gradually increased, affecting the quality of life and academic performance. Objective Analyze the most common sports injuries and offer solutions for the safe practice of college basketball. Methods This article studies, through interviews and literature review, the basketball injuries of college students, analyze the main causes of sports injuries, and presents corresponding countermeasures to promote the safe development of sports education in colleges. Results The main injuries were during training, excessive force, and inadequate preparation. Deficient muscle work is also associated with most of these injuries. Conclusion Basketball is highly competitive and popular on college campuses. It is a sport that can exercise and enrich the extracurricular life of college students, requiring from its practitioners greater attention in the pre-training warm-up phase and parallel muscle strengthening to reduce its major injuries in college students. Level of evidence II; Therapeutic studies - investigation of treatment outcomes

Ukraine has favorable climatic and soil conditions for the cultivation of various niche crops, including buckwheat, which is in great demand on the market of Ukraine and other countries. The article provides measures to improve the technology of growing buckwheat with a high level of adaptability for specific growing conditions during the biologicalization of technological measures, the latest research and publications are elaborated; objectively assessed the importance and relevance of research on the issue of controlling weed vegetation during early spring and pre-sowing cultivation and harrowing with light harrows in phase 1-2 buckwheat leaves, which effectively reduce the level of weediness in buckwheat crops at the initial stages of growth and development of cultivated plants, because the sprouts of buckwheat plants are less competitive with weeds; optimization of the main nutrients during the treatment of buckwheat seeds before sowing with microbiological preparations that improve the morphobiological indicators of cultivated plants and subsequently affect the formation of the yield of buckwheat seeds when growing it in the soil and climatic conditions of the Pravoberezhny Forest Steppe. The results of the study of the influence of various preparative forms of processing buckwheat seeds with biological preparations on the formation of the yield of buckwheat seeds of the highly productive domestic variety Antaria were analyzed. It was determined that the use of various methods of processing buckwheat seeds by inoculation and treatment with biostimulants before sowing is an effective technological measure that allows to significantly increase the productivity of buckwheat agrocenoses with the lowest energy costs. As a result of agrotechnical measures, it was noted that early spring and pre-sowing cultivation + harrowing in the phase of 1-2 leaves on crops of Antaria buckwheat significantly led to the death of weeds. In areas where, in addition to agrotechnical measures, inoculation with Diazophyte and biostimulant Biocomplex of BTU was carried out, the number of weeds decreased by 34%, compared to areas where buckwheat seeds were treated with microbiological preparations and early spring and pre-sowing cultivation was carried out. To effectively control weeds in buckwheat agrocenoses, early spring and pre-sowing cultivation + harrowing should be carried out in the phase of 1–2 buckwheat leaves. Before sowing, buckwheat seeds should be treated with the microbiological preparation Diazofit + biostimulant Biocomplex BTU (100 ml. + 150 ml per hectare rate of seeds). These measures will contribute to the reduction of weeds by up to 36% and the possibility of obtaining a yield of buckwheat grain at the level of 1.54 t/ha.

Objective The ultimate goal of athletic training is to perform the optimum competitive states in the competitions. The research has shown that one of the key factors to achieve the goal is effective and appropriate Tapering in preparing period. By systematically and completely tracing and summarizing the Tapering in endurance events with altitude training at the entire training period which could provide a better guidance for the training and bring into an furthest effects, providing a real reference cases for achieving competitive targets and scientific training. Methods Have Selected 20 players and 10 games from annual competitions (National Championships, the National Games, World Games, Olympic qualifiers etc.) from 2011 to 2017, which involved 9 players who are the international master athletes and 11 players who are the National master athletes with 4-10 years of training. According to entire preparing period schedule and training targets to analyze the intensity, volume and rhythm of training, recording the athletes whose Hb(hemoglobin) number in different circulatory sports and concluding the athlete’s Tapering mode and effects. Results 1. The systematical time of preparing for competition was 65±5 days; 2. The entire training arrangements comprised of four stages: the plain training preparation phase, the altitude training phase, the plain training, pre-competition training phase; 3. Applied single peak and single cycle training model, the training structure was cycling 12 to 15 to 10 to 15 to 26kms, and the maximum training interval was 5-7 days after highest intensity training. 4. The tapering was engaged in the first week before the altitude training phase and 10-12days before competition; 5. The training load decreased 10-15%,the training intensity decreased by 25%-30% and the training volume was maintained to 90-105% during the first Tapering which mainly decrease training intensity; 6. During the second Tapering, the training load decreased by 40-60%, the training intensity was 90%-95% and at the key class, training intensity was more than 100% which mainly decrease training volume; 7. The training frequency was kept at 95-105% at two Tapering training phases; 8. Athletes’ Hb number was maintained at 132.04 ±6.53IU. The whole adjustments varied with the Tapering training arrangements. Conclusions 1. There were two Tapering training models with altitude training characteristics before the preparing competition period; 2. The one Tapering was decreasing training volume passively at the beginning of the altitude training, and the another Tapering was decreasing volume initiatively before the competition. 3. The first Tapering was to reduce the intensity of training, and the second Tapering was to reduce the volume of training; 4. The first Tapering is last 5 to 7days, and the second Tapering last 10 to 12days; 5. The entire preparing preformed as hyperbolic mode. The first tapering was the exponential tapering(slow decay), and the second tapering was the exponential tapering(fast decay); 6. The athletics’ function capacity changes vary with the changes of Tapering. When the ability of adaption was quicker, the competitive states improved.

AbstractEngagement in physical activity, across various sports, promotes a diverse microbiota in active individuals. This study examines the gut microbiota of Colombian athletes, specifically weightlifters (n = 16) and road cyclists (n = 13), compared to non‐athletes (n = 15). Using Kruskal–Wallis tests, the physical activity level of a group of non‐athletic individuals and the sports experience of a group of professional athletes is analyzed. The median age of participants is 24 years, comprising 25 men and 19 women. The microbiota is collected using fecal samples. Participants provided these samples during their pre‐competitive stage, specifically during the concentration phase occurring two weeks prior to national competitions. This timing is chosen to capture the microbial composition during a period of heightened physical preparation. Questionnaire responses and microbial composition assessments identify disparities among groups. Microbial composition analysis explores core microbiome, abundance, and taxonomy using Pavian, MicrobiomeAnalyst 2.0, and GraPhlAn. ANCOM‐BC2 reveals differentially abundant species. Road cyclists exhibit decreased Bacteria and increased Archaea abundance. Phylum‐level variations included Planctomycetes, Acidobacteria, and Proteobacteria, while Bacteroidetes prevailed. Key families influencing gut microbiota are Bacteroidaceae, Muribaculaceae, and Selenomonadaceae. Weightlifters exhibit unique viral and archaeal community connections, while cyclists showed specialized microbial interplay influenced by endurance exercise. Correlation network analysis emphasizes distinctive microbial interactions within athlete groups, shedding light on the impact of physical activities on gut microbiota and athlete health.

Background: Over a life-course, human adaptive immunity to antigenically mutable pathogens exhibits competitive and facilitative interactions. We hypothesize that such interactions may lead to cyclic dynamics in immune responses over a lifetime.Methods: To investigate the cyclic behavior, we analyzed hemagglutination inhibition titers against 21 historical influenza A(H3N2) strains spanning 47 years from a cohort in Guangzhou, China and applied Fourier spectrum analysis. To investigate possible biological mechanisms, we simulated individual antibody profiles encompassing known feedbacks and interactions due to generally recognized immunological mechanisms.Results: We demonstrated a long-term periodicity (about 24 years) in individual antibody responses. The reported cycles were robust to analytic and sampling approaches. Simulations suggested that individual-level cross-reaction between antigenically similar strains likely explain the reported cycle. We showed that the reported cycles are predictable at both individual and birth-cohort level and that cohorts show a diversity of phases of these cycles. Phase of cycle was associated with the risk of seroconversion to circulating strains, after accounting for age and pre-existing titers of the circulating strains.Conclusions: Our findings reveal the existence of long-term periodicities in individual antibody responses to A(H3N2). We hypothesize that these cycles are driven by pre-existing antibody responses blunting responses to antigenically similar pathogens (by preventing infection and/or robust antibody responses upon infection), leading to reductions in antigen specific responses over time until individual's increasing risk leads to an infection with an antigenically distant enough virus to generate a robust immune response. These findings could help disentangle cohort-effects from individual-level exposure histories, improve our understanding of observed heterogeneous antibody responses to immunizations, and inform targeted vaccine strategy.Funding: This study was supported by grants from the NIH R56AG048075 (D.A.T.C., J.L.), NIH R01AI114703 (D.A.T.C., B.Y.), the Wellcome Trust 200861/Z/16/Z (S.R.) and 200187/Z/15/Z (S.R.). This work was also supported by research grants from Guangdong Government HZQB-KCZYZ-2021014 and 2019B121205009 (Y.G. and H.Z.). D.A.T.C., J.M.R. and S.R. acknowledge support from the National Institutes of Health Fogarty Institute (R01TW0008246). J.M.R. acknowledges support from the Medical Research Council (MR/S004793/1) and the Engineering and Physical Sciences Research Council (EP/N014499/1). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

This keynote lecture is a product of many years of hard work but today this is delivered in honor of Professor and Founding President of ORLIAC, Professor Emeritus Jan Veldman. Thank you for the opportunity to host ORLIAC in Manila way back in March 2018. For those who attended this, I gave a special lecture during the celebration of World Hearing Day on March 3, 2018, when ORLIAC was held in Manila and this gives an update on how we managed in the past four and a half years, with a COVID-19 pandemic in the past two and half years. The Philippines is an archipelago of more than 7,100 islands during high tide and up to 7,600 when it is low tide. It is situated in the Southeast Asian region. It is one of the countries with the highest population density, with a total population of 110 million spread over 300,000 square kilometers. The crude birthrate is at 19.9 per 1000 – in stark contrast with surrounding Southeast Asian nations now with a decreasing population such as Thailand, Vietnam, and Malaysia among others There have been three World Health Assembly (WHA) resolutions that emphasized the prevention of deafness and hearing loss. WHA 38.19 in 1985 then ten years later WHA 48.9 in 1995 and the last WHA 70.13 in 2017. These resolutions from the World Health Assembly emphasized that prevention of deafness and hearing loss should be incorporated in primary health care. As a result of the 2017 WHA 70.13 resolution, a World Hearing Report1was formulated and released last year in 2021 (Figure 1). The WHO Call to Action in 2000 recommended that Universal Newborn Hearing Screening (NHS) be implemented in all countries where rehabilitation services are established.2 In 1998, we did the first cochlear implantation in my country3 and established as well the graduate program of Masters in Clinical Audiology at the UP College of Medicine where I now work as Dean. This graduate program is one of only two in the country and is government-subsidized such that slots are limited and entry is quite competitive. It is jointly offered with the College of Allied Medical Professions.4 We consider this program to be a key element in producing the necessary healthcare workforce needed for the implementation of programs to defeat deafness in my country. The world hearing report published last year by the World Health Organization (WHO) highlighted the increasing number of people living with hearing loss and in need of services. There is of course the disproportionate burden of hearing loss in low-to middle-income countries like the Philippines.6Our publications from 2003, from a study looking at results of newborn hearing screening in the neonatal intensive unit in the hospital7,8 then to the community, thus providing the evidence for the eventual policy on UNHS that we proposed to the Department of Health (DOH) and to congress for legislation.We initially embarked on basic epidemiological studies using otoacoustic emissions testing in the hospital then in the community. We noted the age of referral at our hospital for children with hearing impairment to be at around 34 months.9 Our focus then was just providing otological clinical services so we decided to work for the establishment of the Philippine National Ear Institute (PNEI) – a research institute formed by Republic Act 9245 and part of the National Institutes of Health of the University of the Philippines – Manila.10 The PNEI laid down the researches needed for the stable foundation of a national health program focused on newborn hearing. From 2003 to 2008, we conducted several studies to establish the prevalence of bilateral permanent hearing loss in newborns both in the hospital and community settings as a prelude to the enactment of the law, and in order to defend having a program on newborn hearing, we conducted a cost-analysis of hospital-based universal newborn hearing screening.11 Notably in 2007, a population-based study showed the prevalence of bilateral profound Congenital Hearing Loss at 1.4 per 1000 births.12 This translates to more than 3,000 babies annually or 8 babies per day who may be profoundly deaf in my country.13 If there were proper intervention for a child with hearing impairment, the cost of treating hearing translates to a lifetime savings of about 80,000 dollars or about PhP 4.3M for the patient’s family. The government and the family would have spent about PhP 4.3 M to raise, educate, and support a deaf-mute child to adulthood. This was presented to the Senate of the Philippines and highlighted during the Inaugural Congress of the ASEAN Academy of Neuro-Oto-Audiology (AANOA). This was supported by Senator Loren Legarda, PNEI Director Dr. Generoso Abes, AANOA founding member Dr. Helmi Balfas, IFOS Regional Secretary Chong Sun Kim, PSOHNS President Gil Vicente, AANOA President Dato Lokman Saim, and Hearing International Secretary Dr. Norberto Martinez (Figure 2). Mandating NHS in the country also entailed involving stakeholders, including otolaryngologists from the different regions who committed to convince their local officials and local hospital administrators the need for instituting these newborn hearing screening programs. After we had the local data at hand, the PSOHNS created a task force on NHS and crafted a position statement on the need for UNHS. As then Vice President, we drafted the position paper that will be presented to Congress while at the same time seeking support from the Department of Health under DOH Secretary Francisco Duque who agreed that Philhealth should be able to support this program when enacted into law. A Technical Working Group was formed, gathering all stakeholders and service providers. Multiple meetings were held, groundwork for launch, and implementation of newborn hearing screening program were instituted with ten Collaboration for Newborn Hearing Screening Advocacy (CONHScA) annual symposia with otolaryngology, audiology, and other hearing screening advocates all over the country.14 (Figure 3). On August 12, 2009, President Gloria Macapagal-Arroyo signed RA 9709, an act that established universalnewborn hearing screening program for the prevention, early diagnosis, and intervention of hearing loss.15 On the modality to be used, reporting, accreditation and training, monitoring and evaluation, and most especially costing of the services and financing for sustainability were also done. We advocated for legislation on UNHS, and once ratified, developed a national program with the Department of Health as lead agency and continued with policy implementation as part of a national technical working group under the DOH. This led to the creation of national Newborn Hearing Screening Reference Center (NHSRC) that was inaugurated in 2013 at the National Institutes of Health with Professor Cor Cremers of Radboud University Nijmegen as special guest. We also started to increase the awareness on the importance of NHS even on national television (Figure 4). Aside from the cost-effectiveness study of hospital-based newborn hearing screening program, we also looked at the budget impact of a community-based UNHSP in the Philippines from both the public payer and the societal perspectives. This study of Rivera et al. published in 201716 showed that cost effectiveness is sensitive to treatment rate, prevalence, follow-up rate, number of rehabilitation sessions, and coverage of the program. It was not sensitive to cost per rehabilitation session, cost of diagnosis with OAE and ABR, education costs, refer rates, recurrent costs, cost of machines, and sensitivity rates. From the societal perspective, the UNHSP was found to be cost-saving for the full range of parameters tested for cost of screening, amplification, education, rehabilitation, and fixed program costs. Ensuring treatment of at least 31 percent and follow-up rate of 24% for a community-based newborn hearing would likely be important benchmarks. The technical arm of the lead agency for this program, the Department of Health, is the Newborn Hearing Screening Reference Center that gives assistance in defining and recommending NHS testing and follow-up protocols which include hearing screening methods, devices used, location, manner, and timing of newborn hearing screening testing. The current protocol uses the 2007 JCIH recommendation of 1-3-6 rule, with screening at 1 month, confirmation of hearing loss at 3 months, and appropriate intervention at 6 months of age.17 With respect to the preferred method of screening, the recent study by Neumann K et al. showed OAE as most prevalent in the country.18 Ten years ago in 2010, an initial web registry for reporting of the OAE results was formulated up to 2014 it was used in 9 centers which allowed gathering of preliminary data on the NHS program. From the data, there was a registry card that needed manual data encoding and in order to sustain operations, a 1 USD fee was levied per registration and was reimbursable thru Philhealth that paid around 4 USD per hearing screening test done. Personnel training, device, and facility certification standards were implemented for centers that chose to perform newborn hearing screening testing. Tiered categorization of centers was also done with screening centers as Category A, screening and diagnostic centers as category B, screening, diagnostic, and essential intervention with hearing aid amplification as category C, and the highest category D for centers with genetic testing and counselling, cochlear implantation surgery and speech rehabilitation services. Recent data showed there were 1072 category A, 18 category B and C, and 9 category D centers distributed all over the country (Figure 5). While some services were initially hampered by the COVID-19 pandemic, NHSRC defined safety protocols that needed to be followed. In an updated advisory, first released in April 2020, and is still in effect to date, NHSRC emphasizes that the centers should follow hospital/institution’s procedural protocol regarding disinfection and attire. Hearing tests in infants are non-invasive and non-aerosol producing procedures. The advisory also included recommendations in terms of timing, preparation, and testing procedures. One significant development that was accelerated during the pandemic was the online adaptation of the NHS personnel certifying course that was reported in recent publications by Rozul et al.19,20 To date, there have been about 3403 trained personnel in 1099 centers with significant increase noted in 2019 compared to previous years. This was not however reflected in the report of Neumann probably due to the time when data for this publication was collected prior to 2019. From the registry alone, the percent screened in the Philippines has been reported to be at least 7-13 percent of live births from the years 2019-2021. The report from Philhealth of 800 claims for NHS from 2018-2019 is still under verification. In 2020, based on manual submission, out of 1099 facilities, 26 percent submitted reports. In 2019, 95% already submitted reports so the pandemic impacted significantly on reporting of results by excel file and paper reports (Figures 6 and 7). The program is still beset with challenges like poor compliance with data submission, loss to follow-up, poor connectivity, sustainable funding of the program from both local and national government, lack of human resources, and a need of much awareness among stakeholders regarding the importance of newborn hearing screening. In a country where 60 percent die without seeing a doctor, there is much work to do. The cost of screening equipment is a major barrier so we conceptualized a biomedical device development project working with engineers in the university to create an AABR screening device which is now on phase two with a TLR 5 early phase rating scale and will now include recruitment of more subjects and refinements for improvements. Harnessing technology and making this more affordable remain as strategies for developing a sustainable hearing screening program and is the subject of HELE, which aims to increase the rates of newborn hearing screening with novel technologies and telehealth. “Hele” stands for lullaby a mother sings to a child. We thought this as very apt for emphasizing the importance of hearing from birth for optimal development. This received a substantial phase 1 grant in 2016 and a phase 2 was launched this year for the premarket development which now stand at technology readiness level 5. It has already spawned many products like the computer-based e-learning training modules, capacity building with provision of basic OAE equipment, and many research publications. It is hoped that a pre-production HELE device can already be produced soon with validated efficacy and reproducibility of all the AABR responses in a clinical setting. With the collaboration of University of California Berkeley and UC Davis, a formidable team has been created. The electronic national newborn hearing screening registry was launched during WORLD HEARING DAY in 2022 and the usability testing results have been published by Ricalde et al.21 In the recent manual of operations and procedures, success indicators were outlined. This is aligned with the WHO standards for monitoring and evaluation, and determining success of programs. Beyond NHS, what else have we learned? Our studies on the genetic causes of the more common causes of hearing impairment such as otitis media showed a unique mutation A2ML1 that affected protease inhibitors allowing better mucosal defense of the middle ear mucosa. Our findings showed microbiome shifts and when we looked at gingivitis, this was what we found. The genetic counseling we embarked on for this indigenous community taught us clinicians many lessons. Speaking to them in their native language was important and house to house invitations were more effective. What about genetic basis of congenital hearing loss? We have found that SLC26A4 mutations were more common than GJB2. There were novel mutations seen in our cohort suggesting the need for studies looking at genetic predisposition. We saw commonalities with Indonesia in terms of the prevalence of GJB2 mutations. From our studies on A2ML1 mutations predisposing to otitis media, we are monitoring this with ongoing study on Hispanic populations. Meanwhile, a seed fund for a national cochlear implant program was approved by Congress and 20 children underwent surgery (Figure 8), while two centers, one in Visayas (Corazon Locsin Montelibano Memorial Regional Hospital in Bacolod) and another in Mindanao (Southern Philippines Medical Center in Davao) were capacitated. Virtual multidisciplinary meetings to discuss the cases were held and provided a model for optimizing use of resources and outcomes. The initial data from the 20 implanted children are very encouraging. There are goals of expanding this program to more beneficiaries by having a Z package for Cochlear implantation, funding from DOH medical assistance fund for indigent patients, and development of services for other implantable hearing devices at the Philippine General Hospital. Moreover, research on hearing need more support given that our studies on genetics of hearing loss among Filipinos yielded very important data on novel genes, uniqueness of our genetic pool as well as mutations predisposing to increased prevalence of otitis media among our marginalized and indigenous population.22-26 As a low- to middle-income country, these researches will need to be continued and may provide valuable lessons for similarly challenged countries in the works as we highlighted in 2017 during the United Nations World Hearing Assembly Advocacy Event on hearing health (Figure 9). The recent National Academy of Science and Technology health policy forum where Professor Xing Kuan Bu was featured as keynote lecturer gave important data on experiences on hearing health program development in China and in the world (Figure 10). Clearly the sustainable development goals especially 3,4,8 and 10 covered by hearing health ensures equity and should be aspirational goals for national development. This is congruent with the vision of PNEI: “No Filipino shall be deprived of a functioning sense of hearing and balance.” Lastly, as the theme of this congress is East Meets West, the Philippines had a strong history of shipbuilding in an era when the galleon trade was very active and 148 of 200 ships that plied that route were ships built in the Philippines with our hardwood. Tracing therefore the history of the countries in ASEAN in particular with the Dutch, French, British, and Spanish influences, we need to dig deeper and look at genetic markers for both health and disease so that while we develop our friendship and scientific connections, history will prove that we have always been connected in so many ways and further exploration can be done in many dimensions. Charlotte M. Chiong, MD, PhDResearch Professor 12Project Leader of HeLeDean, UP College of Medicine (2018-present) _____________________________Paper presented in the Otology Rhinology Laryngology International Academic Conference, September 26, 2022, Auditorium Antonianum, Rome, Italy. Paper prepared in fulfillment of the Alfredo T. Ramirez Professorial Chair for 2022.

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). 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[11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). 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AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. Percentage of all active physicians by race/ethnicity, 2018 | AAMC. (2018). AAMC. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 [32] Ramirez, et al. (2021). [33] Passel, et al. (2022). [34] Census Reporter. (n.d.). Census profile: Manhattan borough, New York County, NY. https://censusreporter.org/profiles/06000US3606144919-manhattan-borough-new-york-county-ny/ [35] MD Student Diversity Recruitment. (2022). NYU Langone Health. https://med.nyu.edu/our-community/why-nyu-grossman-school-medicine/diversity-inclusion/recruiting-diversity/md-student-diversity-recruitment [36] NYU. (n.d.). STEP Pre-College Program. New York University. https://www.nyu.edu/admissions/undergraduate-admissions/how-to-apply/all-freshmen-applicants/opportunity-programs/pre-college-programs.html [37] Association of American Medical Colleges. (2022). NYU Grossman School of Medicine. Medical School Admission Requirements (MSAR). https://mec.aamc.org/msar-ui/#/medSchoolDetails/152 [38] Association of American Medical Colleges. (2022). [39] U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: Philadelphia County, Pennsylvania. Census Bureau QuickFacts. https://www.census.gov/quickfacts/philadelphiacountypennsylvania [40] Association of American Medical Colleges. (2022). Drexel University College of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/833 [41] Association of American Medical Colleges. (2022). [42] Drexel University College of Medicine. (n.d.). Diversity, Equity & Inclusion For Students. https://drexel.edu/medicine/about/diversity/diversity-for-students/ [43] Drexel University College of Medicine. (n.d.-b). Drexel Pathway to Medical School. https://drexel.edu/medicine/academics/graduate-school/drexel-pathway-to-medical-school/ [44] Drexel University College of Medicine. Drexel Pathway to Medical School. [45] Association of American Medical Colleges. (2022). University of California, San Francisco, School of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/108 [46] The Regents of the University of California. (n.d.). Differences Matter. UCSF School of Medicine. https://medschool.ucsf.edu/differences-matter [47] The Regents of the University of California. (n.d.-b). Post Baccalaureate Program | UCSF Medical Education. UCSF Medical Education. https://meded.ucsf.edu/post-baccalaureate-program [48] United States Census Bureau. (2021). U.S. Census Bureau QuickFacts: San Francisco County, California. Census Bureau QuickFacts. https://www.census.gov/quickfacts/sanfranciscocountycalifornia [49] Memorial Sloan Kettering Cancer Center. (n.d.). Student Programs. https://www.mskcc.org/about/leadership/office-faculty-development/student-programs [50] Alsan, et al. (2021). [51] National Health Service Corps. (2021, November 2). Mission, Work, and Impact | NHSC. https://nhsc.hrsa.gov/about-us [52] Elam, C. L., & Wagoner, N. E. (2012). Legacy Admissions in Medical School. AMA Journal of Ethics, 14(12), 946–949. https://doi.org/10.1001/virtualmentor.2012.14.12.ecas3-1212