United States

Background
Systemic isotretinoin is a highly effective treatment for severe and refractory acne but carries risk for serious adverse effects such as teratogenicity. The United States’ risk mitigation system, iPLEDGE, requires all patients on isotretinoin therapy to complete monthly tasks including follow-up visits with their prescriber, and patients with childbearing potential must additionally undergo monthly pregnancy testing. The onset of the COVID-19 pandemic presented an opportunity to reduce the isotretinoin gender gap, as updated regulations shifted to permit at-home pregnancy testing and telehealth visits for monthly follow-ups.

Methods
We performed a single-center analysis to determine whether gender differences in isotretinoin prescription changed at our institution during the initial months of the pandemic. Data was obtained from an institutional database. Inclusion criteria were dermatology encounters during which an adult patient (age&gt;18) was prescribed isotretinoin or topical retinoids for acne. Gender identity originated from patient-reported demographics. Fisher’s exact tests with alpha set to 0.05 were used to compare odds of isotretinoin prescription for male and female patients, with control groups comprised of patients receiving topical retinoids for acne. Odds ratios were compared for the pandemic period (June 1, 2020 to January 22, 2021) versus the pre-pandemic period (June 1, 2019 to January 22, 2020). Odds ratios were also compared between telehealth visits and in-person visits during the pandemic period.

Results
We found that male predominance of isotretinoin prescriptions was greater during the pandemic compared to pre-pandemic (odds ratios: 4.13 vs. 2.86). Furthermore, male patients were more likely to utilize telehealth compared to in-person visits relative to female patients (odds ratios: 6.00 vs. 3.62).

Conclusion
Despite the newly introduced flexibilities of telehealth and remote pregnancy testing, gender inequity in receiving isotretinoin treatment persisted during the pandemic. Many factors may influence the relative decreased access to isotretinoin among female patients including patient and provider preference. Future work should examine factors influencing the prescription of isotretinoin to female patients, as well as identify opportunities to improve policies that promote safe isotretinoin use while minimizing gender inequity.

AMA Research Challenge 2022

Differences in isotretinoin access by gender during the initial months of the COVID-19 pandemic

Background
Systemic isotretinoin is a highly effective treatment for severe and refractory acne but carries risk for serious adverse effects such as teratogenicity. The United States’ risk mitigation system, iPLEDGE, requires all patients on isotretinoin therapy to complete monthly tasks including follow-up visits with their prescriber, and patients with childbearing potential must additionally undergo monthly pregnancy testing. The onset of the COVID-19 pandemic presented an opportunity to reduce the isotretinoin gender gap, as updated regulations shifted to permit at-home pregnancy testing and telehealth visits for monthly follow-ups.

Methods
We performed a single-center analysis to determine whether gender differences in isotretinoin prescription changed at our institution during the initial months of the pandemic. Data was obtained from an institutional database. Inclusion criteria were dermatology encounters during which an adult patient (age>18) was prescribed isotretinoin or topical retinoids for acne. Gender identity originated from patient-reported demographics. Fisher’s exact tests with alpha set to 0.05 were used to compare odds of isotretinoin prescription for male and female patients, with control groups comprised of patients receiving topical retinoids for acne. Odds ratios were compared for the pandemic period (June 1, 2020 to January 22, 2021) versus the pre-pandemic period (June 1, 2019 to January 22, 2020). Odds ratios were also compared between telehealth visits and in-person visits during the pandemic period.

Results
We found that male predominance of isotretinoin prescriptions was greater during the pandemic compared to pre-pandemic (odds ratios: 4.13 vs. 2.86). Furthermore, male patients were more likely to utilize telehealth compared to in-person visits relative to female patients (odds ratios: 6.00 vs. 3.62).

Conclusion
Despite the newly introduced flexibilities of telehealth and remote pregnancy testing, gender inequity in receiving isotretinoin treatment persisted during the pandemic. Many factors may influence the relative decreased access to isotretinoin among female patients including patient and provider preference. Future work should examine factors influencing the prescription of isotretinoin to female patients, as well as identify opportunities to improve policies that promote safe isotretinoin use while minimizing gender inequity.

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Extensive Risk Factor Evaluation and Long-Term Assessment of Actinic Keratosis

Abstract Title: Investigating and summarizing information resources for the clinical presentation and diagnosis of cutaneous manifestations of infectious diseases in patients with skin of color (SOC).

Background: Skin of color presents disease differently in many circumstances, yet we see a lack of information regarding the presentation and diagnosis of cutaneous manifestations, specifically of those with SOC who are experiencing infectious disease. Many studies have found that SOC is underrepresented in preclinical courses for medical students and may later lead to misdiagnosis of diseases in dark-skinned populations (Louie & Wilkes, 2018; Mangione-Smith et al., 2004; Martin et al., 2016; Tsai et al., 2016). Because SOC is less represented in medical textbooks, patients with diseases such as Lyme disease presenting with cutaneous manifestations such as Erythema migrans may experience a delay in diagnosis (Fix, 2000; Ly, 2021; Palmieri, 2019). 

Methods: The databases PubMed and ScienceDirect were used to acquire research and review articles. Only resources provided in English were considered in the literature search. Articles were reviewed if they addressed cutaneous manifestations of infectious diseases in patients with SOC as a key topic. Only articles after the year 1980 were included. For inclusion, articles needed to include information regarding cutaneous manifestations of infectious diseases, specifically in patients with SOC. Articles were excluded if they contained no information regarding both Infectious disease and SOC. Duplicates were also removed. 

Results: Overall, 17 articles were identified out of 2,565 results. Searches regarding the general phrase “skin manifestations of infectious disease in “dark skin” and “HIV in "pigmented skin" yielded the most results. Many articles contained only a few sentences regarding infectious disease manifestations in patients with SOC. HIV had the highest representation of infectious disease cutaneous manifestations in patients with SOC, with five of the seventeen articles pertaining to the discussion of HIV in patients with SOC. 1,5,6,11,14,15. The most recent article discussed a study looking at the use of Perceptual and Adaptive Learning Modules (PALMs) to increase skin assessment in patients with SOC

Conclusion: This review identified significant gaps in the literature regarding cutaneous manifestations of infectious disease in SOC, such as lack of visual examples and representations of common infectious diseases in Skin of Color. Healthcare disparities in both Infectious Disease and Dermatology are present and affect the care of patients with skin of color. Increased research is needed in both fields, as well as collaboration between fields to help alleviate the barriers patients with skin of color face when obtaining care.


Investigating and summarizing information resources for the clinical presentation and diagnosis of cutaneous manifestations of infectious diseases in patients with Skin of Color.

Racial and ethnic factors associated with differences in the receipt of treatments for patients with mycosis fungoides, a type of cutaneous T-cell lymphoma

Jessica B. Brown-Korsah, BS1, Larissa De Souza, BS1, Kevin D. Cooper, MD1,2

1Case Western Reserve University School of Medicine, Cleveland, OH, USA

2 Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA

Background: Previous studies have demonstrated an association between Black race and poorer overall survival for patients with mycosis fungoides (MF). As for Hispanic patients (HPs) with MF, little is known within the literature.1–4 Due to the impact treatment may have on overall survival, we identified racial and ethnic factors associated with the receipt of treatment for MF.

Methods: A retrospective analysis of 8257 eligible patients diagnosed with MF between 2004 – 2017 within the National Cancer Database (NCDB) was performed. Multivariate logistic regression was used to identify sociodemographic factors, clinical factors, and the receipt of treatment (immunotherapy, chemotherapy, radiation, or other treatments) associated with non-Hispanic Black patients (NHBPs) and Hispanic patients (HPs), compared to non-Hispanic White patients (NHWPs). Covariates included age, sex, stage, median household income, facility type, insurance status, metro/non-metro, and Charlson-Deyo score.

Results: NHBPs and HPs consisted of 20.2% and 6.4% of patients within the study, respectively. NHBPs were less likely to receive radiation compared to NHWPs, adjusting for sociodemographic and clinical factors (aOR 0.71; 95% CI: 0.58 – 0.86; P= <.001). NHBPs were more likely to receive other treatments such as psoralen and long-wave ultraviolet radiation (PUVA) (aOR 1.39, 95% CI: 1.22 – 1.60, P = <.001). HPs were more likely to be diagnosed with Stage 4 disease (aOR 2.67; 95% CI: 1.73 – 4.03; P= <.001). No differences were noted in the receipt of treatment due to Hispanic ethnicity. 

Conclusions: NHBPs with MF were 29% less likely to receive radiation compared to NHWPs. NHBPs were 39% more likely to receive other treatments like PUVA, after adjusting for sociodemographic and clinical factors. HPs were nearly 3 times more likely to be diagnosed with Stage 4 disease compared to NHWPs, after adjusting for sociodemographic characteristics and stage. These results underline possible difficulties in accessing equitable therapies for NHBPs with MF.

References
1. Su C, Nguyen KA, Bai HX, et al. Racial disparity in mycosis fungoides: An analysis of 4495 cases from the US National Cancer Database. J Am Acad Dermatol. 
2017;77(3):497-502.e2. doi:10.1016/j.jaad.2017.04.1137 
2. Nath SK, Yu JB, Wilson LD. Poorer prognosis of African-American patients with mycosis fungoides: An analysis of the SEER dataset, 1988 to 2008. Clin Lymphoma, Myeloma Leuk. 2014;14(5):419-423. doi:10.1016/j.clml.2013.12.018
3. Sun G, Berthelot C, Li Y, et al. Poor prognosis in non-Caucasian patients with early-onset mycosis fungoides. J Am Acad Dermatol. 2009;60(2):231-235. doi:10.1016/j.jaad.2008.09.063
4. Choi J, Sutaria N, Roh YS, et al. Racial and ethnic disparities in inpatient health care utilization for mycosis fungoides: A cross-sectional analysis of the 2012-2017 National Inpatient Sample. J Am Acad Dermatol. 2022;86(6):1408-1410. doi:10.1016/j.jaad.2021.06.00

Race and ethnicity associated with differences in the receipt of treatment for mycosis fungoides

Background: 
Although white patients have higher incidence of melanoma, clinical outcomes are worse among patients with skin of color. This disparity arises from delayed diagnoses and treatment that are largely due to clinical and sociodemographic factors. These include: atypical presentation, decreased skin health literacy, stereotype threat, limited access to dermatologists, and poverty rates. Investigating these disparities is crucial to decrease the disparity in melanoma-related mortality rates in minority communities.

Methods: An extensive search of current literature was conducted using PubMed Database. Articles focusing on melanoma diagnoses, treatment, and race were reviewed to determine the current state of literature on melanoma, racial disparities, and health literacy. A 16 question survey was designed and deployed via Qualtrics to measure whether the presence of racial disparities in dermatologic awareness exists and if they may be due to social and economic factors. The survey was distributed on various social media platforms, and sites related to skin cancer or melanoma. Over 300 results were recorded and the extracted data was analyzed using SPSS software.

Results: 
Of the 308 respondents, white patients were significantly more likely to have higher perceived risk of developing skin cancer, highest self reported understanding of UV scale, highest levels of sunscreen usage, and higher reported frequency of skin checks performed by primary care providers (PCPs). There was no difference in levels of melanoma education provided by PCPs among different racial groups, and no significance identified in the highest level of patient education perceived melanoma risk. 

Conclusion:
Initial literature analysis suggests attribution of racial disparities in skin cancer to inequity in primary care settings. As a result of differential presentation and lack of dermatologic access both geographically and financially, there is delayed diagnosis and treatment time. The survey findings above do not suggest inadequate dermatologic literacy as provided in healthcare settings, but rather inadequate dermatologic health literacy as a result of other outlets such as public health and skin product marketing. Outlets such as racial stereotypes in communities, implicit biases in marketing companies, and public health campaigns should be considered. Further studies should be conducted to determine these biases and improve education in communities of color. 



Racial Disparities in Melanoma: Barriers to Diagnosis, Treatment and Health Literacy

Background
Patients experiencing homelessness (PEH) are at high risk of skin cancers due to the amount of sun exposure they receive on a daily basis. Skin disease can be overlooked and underdiagnosed in PEH due to their lack of access to healthcare, and connecting patients to appropriate specialists is a major hurdle in bridging their health disparities. Miami Street Medicine (MSM) is an organization that connects PEH in the Miami Medical District with longitudinal care. This project aims to raise awareness about the risk of skin cancers in PEH and describe a way MSM was able to bridge care for an unhoused patient with melanoma.
Methods
PEH encountered during weekly mobile clinics from January - May 2022 were provided basic medical care (vitals, wound care, medications) followed by a skin survey. A board-certified dermatologist was consulted for conditions with low diagnostic certainty. Further, patients were provided with guided treatments for their condition. Patients with high-risk lesions were connected to low-income clinical resources for further management and were concurrently followed by Street Medicine teams to improve treatment access and adherence.
Results
Among 106 patients interviewed, 102 skin conditions were diagnosed. A total of 8 lesions (7.8%) found were suspicious for cancer or pre-cancer, with 1 pathology-confirmed melanoma. Numerous barriers to care were encountered such as insurance limitations, lack of health literacy, transport issues, and lack of social support which made appointment adherence challenging. The patient with a lesion suspicious for melanoma was followed closely and scheduled for further evaluation, with eventual pathology confirmation of melanoma-in-situ. He is currently being followed by a multidisciplinary team including mental health professionals, and surgically evaluated for excision and reconstruction.
Conclusion
Skin cancer is an area of concern for PEH because of their extensive sun exposure. For many PEH, inpatient hospitalization is often the only way to access specialty care. This means that a multifaceted approach is required to improve treatment adherence, which can also include point-of-care testing or telemedicine specialist consultations. Street medicine can be a valuable adjunct to improving longitudinal care among PEH by bridging the gaps that prevent follow-up in the current healthcare delivery model.

Skin cancers among the unsheltered: a Street Medicine perspective

Background: Wildfires are a worsening public health crisis, threatening human health and healthcare infrastructure. Of the largest wildfires in California since 1878, four occurred in 2021 and five in 2020. Despite the increasing frequency of healthcare facility and community evacuations due to wildfires, little is known regarding the extent of wildfire threat to healthcare access in California. We examine where inpatient healthcare facilities are at the greatest risk of potential structural damage or facility evacuation based on fire threat data.

Methods: Inpatient facility locations including i) general and acute care hospitals, ii) behavioral health facilities, and iii) long term care facilities were mapped in relation to CAL-FIRE Fire Threat Zones (FTZs), which combine expected fire frequency with potential fire behavior. The threat zones within a half-mile and one-mile radius of each facility were computed and recorded as a metric of potential threat to the physical structure, operation, or accessibility of the facility. Regional risk profiles to facilities and facility capacity were calculated.

Results: Of 3,096 inpatient healthcare facilities, 908 (29%) are within 0.5-miles of a “high”, “very high,” or “extreme” FTZ (‘higher’ FTZ), and 1,514 (49%) within one mile. In 18 counties, 100% of inpatient healthcare facilities are within 0.5 miles of higher FTZ; in 25 counties (population 2.6 million), 100% of inpatient healthcare facilities are within one mile of higher FTZs. 67% of the inpatient healthcare facility capacity in California is within one mile of a higher FTZ. 

Conclusion: A substantial proportion of California’s inpatient healthcare infrastructure is threatened by wildfire, and this risk is unevenly distributed. In northern counties – where two of California’s largest fires burned more than one million acres in the last two years – healthcare accessibility is a significant concern because of high levels of hazard exposure and limited total number of facilities, meaning loss of a single facility can substantially affect healthcare access. As climate change and other factors raise wildfire risk, it will be important to invest in measures to protect inpatient healthcare facilities and ensure that these facilities continue to meet the healthcare needs of their communities.


An Analysis of Wildfire Threat to Inpatient Healthcare Facilities in California

Background
Depression is a common mental disorder among the geriatric population that reduces the quality of life and increases morbidity and mortality. Vitamin D is a neurosteroid hormone involved in various brain functions. Vitamin D receptors (VDR) are expressed in many brain regions, such as the hippocampus, hypothalamus, and cerebellum. It regulates the gene expression of various neurotransmitters. Furthermore, Vit D enhances the production of serotonin which suppresses depressive symptoms. Vit D deficiency is relevant in older persons and associated with an 8-14% increase in the risk of depression, particularly in subjects with low serum 25-hydroxy-vitamin D (25OHD) levels. The objective of this study is to examine the effect of Vitamin D supplements in the management of depressive symptoms in the elderly.
Methods
We searched PubMed, Google Scholar, and Clinicaltrials.gov to collect the relevant studies that examined the effects of vitamin D supplementation on depression. We used a combination of the keywords; Depression, Vitamin D, Vitamin D supplements, and Elderly to search databases. The studies collected were randomized controlled trials (RCT) in the elderly population, published within the last decade. We excluded non-English articles, observational studies, and animal studies.
Results
We reviewed eight RCTs that matched our predetermined eligibility criteria. The studies included 55,451 male and female participants. The risk and clinical symptoms of depression were assessed between the Vitamin D3 supplement groups and the control groups. Six studies showed no significant reduction in depression symptoms after Vitamin D3 supplementation. The other two studies reported improvement in depressive symptoms and a significant decline in depression scores.
Conclusion
We found a clear association between low levels of 25-hydroxyvitamin D and increased risk of depression in elder persons. However, included clinical trials, except for two studies, did not show a significant correlation between vitamin D3 supplementation and amelioration of depression symptoms in the elderly. Few studies have a small sample size which might be a limitation of this review. Future clinical trials on larger populations and longer duration are needed to investigate the causal relationship and treatment recommendations.




The Effect of Vitamin D Supplements in the Treatment of Depression in the Elderly: Literature Review

Background:
Helicobacter pylori (H. pylori) bacteria has long been scrutinized as one of the potential risk factors for developing pancreatic cancer with inconsistent and unequivocal data. Globally, there is an increasing trend in pancreatic cancer incidence and mortality rates. Little is known about the risk factors involved with this malignancy. In this systematic review, we aimed to examine the relationship between H. pylori infection and pancreatic cancer based on the evidence from the existing observational studies worldwide.

Methods:
We searched major electronic databases such as PubMed, MEDLINE, Science Direct, and Cochrane library using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. After a careful and thorough screening process, we selected 15 observation studies for this systematic review.

Results:
Six of 15 studies found a significant association between H. pylori infection and pancreatic cancer. Additionally, four of these studies found a significant relationship between the Cytotoxin-associated gene-A (CagA) strain of H. pylori and pancreatic cancer.

Conclusion:
Based on the evidence from the selected studies, a weak association was observed between H. pylori infection and cancer of the pancreas, especially in European and Asian populations compared to the North American population. The cross-sectional evidence from the case-control studies only suggests the existence of association but does not provide substantial evidence of the causative relationship. Further, large-scale prospective cohort studies are warranted in the future to understand this contradictory relationship better.

Association between the Helicobacter pylori Infection and the Risk of Pancreatic Cancer

Abstract Title: Cultural adaptation of Web-based Dietary Intervention Platform ALIVE – to improve the dietary inflammatory scores among the African American People in the CHURCH trial.
Soujanya Jammalamadaka, under the guidance of Dr. Lisa Matthews, and Principal Investigator Dr. Olajide A. Williams, Columbia University Irving Medical center.
Background:Structural inequities contribute to the high rates of colorectal cancer(CRC) incidence(49.1%) and mortality rates(23%) among African Americans(AA) compared to other races in the USA. Screening and dietary/lifestyle modification are effective ways of preventing or reducing the risk of CRC. Research suggests that culturally tailored interventions could improve patient health outcomes and highlight the lack of scientific rigor in cultural adaptation. The CHURCH trial is a cluster RCT aimed at preventing CRC in the AA population via screening and dietary/lifestyle modification. The trial employed the Ecological Validity Model(EVM)9 for cultural adaptation of the dietary intervention designed to reduce the consumption of a pro- inflammatory diet known to increase CRC risk.

Methods: The ALIVE platform is an NCI EBCCP-indexed cost-effective lifestyle coaching program with high RE-AIM scores and framework scores for real-world translation. Using the eight targeted EVM dimensions and an antiracism lens guided by Public Health Critical Race Praxis, we adapted the ALIVE platform to be sociocultural, linguistically, and economically appropriate for AA churchgoers. Specific components of the ALIVE platform included small-step goals, motivational messaging, infographics, media components, and health notes. Before applying the EVM, we employed the community-based participatory research(CBPR) approach to identify the barriers and facilitators to participation and specific EVM dimensions for adaptation within ALIVE! A Community Health Worker(CHW) leader incorporated into our committee assembled a small team of CHW leaders(n = 6) to support community decision-making. In partnership with these leaders, we conducted focus groups with 24 AA church members. We administered a semi-structured survey to 34 CHWs to help inform the design and dietary content and identify problematic EMV-related dimensions.
Results: We successfully identified specific EVM dimensions for adaptation within ALIVE! Focus group findings revealed contextualized health issues in a broader social context, such as structural racism and discrimination. Our survey findings guided the content of the ALIVE platform.
Conclusion: Cultural adaptation of a web-based dietary intervention can be conducted using a CBPR framework, which can aid in identifying EVM dimensions of a web-based nutritional intervention targeting CRC. The next phase of our cultural adaptation process will involve micro- adaptation activities involving eight EVM dimensions.

Cultural adaptation of dietary intervention platform - ALIVE! for colorectal carcinoma prevention.

Background:

The United States Preventive Services Task Force recommends colorectal cancer (CRC) screening for all average-risk adults aged 45 years and up1. Fecal Immunochemical Tests (FIT) and FIT/DNA (Cologuard) test are the two most widely used non-invasive tests used for this screening. In the event of a positive test, a diagnostic colonoscopy is recommended within three months of the positive result. As the Covid-19 pandemic continues, hospitals have implemented policies that include strict screening guidelines before procedures such as colonoscopies. The effect of these guidelines and restrictions on elective procedures such as colonoscopy on the interval between a positive non-invasive screening test (NIST) and diagnostic colonoscopy (DC) is not clear.
Study aim: to quantify the interval between a positive NIST (FIT, FIT/DNA) and DC, and to compare these findings to non-pandemic findings from the previous year. 


Methods:
In this retrospective, time-trend analysis, we identified patients within a major hospital system in Indiana who had a positive NIST between January 1, 2019 and June 30. After our original query, we noticed FIT/DNA tests were not coded into the EMR before June 10, 2020, and had to use data from campus-based public and private hospitals to supplement for this time period. Once identified, chart review was performed to determine if/when a patient underwent DC . If a patient’s chart did not show evidence of a DC, we examined the EMR notes to discern whether, when, or why colonoscopy was / was not completed. We measured the interval between NIST result and DC by quarter, comparing results between corresponding times during 2019 and 2020 as well as the first two quarters of 2021. We also measured and compared the proportion of patients with a positive non-invasive test who had not had colonoscopy by 60, 90, and 180 days. 


Results:
Of the 1,379 patients reviewed, 930 (68%) underwent subsequent colonoscopy in the 30-month study timeframe. Colonoscopy completion rates were 72% for the FIT/DNA group, and 47% for the FIT group over the 30-month timeframe. Of the 293 persons who did not elect to have a subsequent colonoscopy, 21 (7.2%) reported that the pandemic kept them from undergoing the procedure. Concern for acquiring COVID-19 from the colonoscopy site was the most common reason for declining colonoscopy in this group, having been mentioned by 8 of the 21 individuals. Other reasons included waiting to get a COVID vaccine before undergoing a procedure or issues with completing required COVID screening before the procedure. Only two individuals (0.7%) were found to have delayed colonoscopy due to a recent COVID infection. The proportion of patients completing a colonoscopy within 90 days of a positive NIST were 83%, 79%, and 83% for 2019, 2020, and 2021, respectively.


Conclusion/Impact:

Overall, the rate of DCs following a positive NIST test did not appear to be significantly affected by the COVID-19 pandemic. Concern of contracting COVID-19 was a more common reason for delay when compared to actual COVID infection. A study evaluating the rate of COVID infection following a colonoscopy procedure may be useful to address the validity of these concerns, the results of which could alleviate (or exacerbate) this issue in the setting of future outbreaks. When compared to Cologuard, patients who had a positive FIT test were more likely to wait longer for a DC. This discrepancy suggests the relationship between providers and their use of FIT vs. Cologuard should be further probed. In addition, studying patient perceptions of both screening procedures may identity reasons for delay.

1. US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965–1977. doi:10.1001/jama.2021.6238


Next from AMA Research Challenge 2022

Extensive Risk Factor Evaluation and Long-Term Assessment of Actinic Keratosis

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