United States

Infection with SARS-COV-2 has shown the ability to damage nearly every organ system in the human body, including the largest organ - the skin. Granuloma annulare (GA) is a rare rash with unclear etiology that presents as annular, erythematous papules or plaques with central clearing. To our knowledge, there has only been one reported case of GA associated with COVID-19 vaccination published thus far. We present the cases of a 54-year-old female and a 66-year-old male who developed generalized GA and localized GA, respectively, following the administration of a COVID-19 vaccine, which worsened with subsequent boosters. This paper reviews the existing literature on GA associated with COVID-19 infection and vaccination, as well as the possible immunological mechanisms underlying the development of GA following vaccination. We especially note the striking similarities in disease morphology and temporal association with COVID-19 vaccination between our 54-year-old female and the first reported case of GA following COVID-19 vaccination. Despite the temporal association between COVID-19 vaccination and the development of GA, the exact causative relationship remains unclear. Further studies are needed to elucidate the underlying mechanisms and determine the true incidence and risk factors for GA associated with COVID-19 vaccination.

AMA Research Challenge 2023

Granuloma Annulare Onset Following COVID-19 Vaccination

poster

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Background: 
Sunscreen use in people of color is less common than sunscreen use in people with lighter pigmentation, often due to low perceived risk. However, it is still recommended that people of color wear sunscreen to lower the risk of skin cancer, dyspigmentation and pigmentary disorders, and sunburns. Thus, public health efforts should be utilized to improve sunscreen use in people of color. TikTok, a popular social media platform, has been used by health professionals to disseminate educational information and for the purpose of public health outreach. This study looks at the discussion of sunscreen use in this population on this popular social media platform with the goal of understanding what information is being disseminated by and for this target population.

Objective: 
To understand the discussion of sunscreen-related topics on popular social media created for or by people of color.

Methods: 
The term “sunscreen” was searched on TikTok and the top 100 related hashtags were reviewed. Of these two hashtags, #SunscreenforBlackPeople and #Sunscreen for POC, were directed towards people of color. The top 50 videos for each of those hashtags were reviewed for content, creator characteristics including Fitzpatrick skin type and qualifications, and qualities of sunscreen discussed in the video. Analysis was performed to identify key themes in the videos.

Results: 
Most of the content creators discussing the topic of sunscreen for people of color were influencers without medical background. The majority of videos were focused on recommending or sampling different sunscreen brands. Common criteria for reviewing sunscreen brands included presence of “whitecasting”, the final finished look after sunscreen application, cost, and sunscreen density in regard to if the sunscreen feels heavy or lightweight. Only 5 of the top 50 videos contained an educational component. Educational topics included how much sunscreen to put on, importance of reapplication, and reasons to wear sunscreen. Additionally, few videos discussed reasons people of color should wear sunscreen. Of the reasons to wear sunscreen, most commonly discussed were anti-aging and prevention of hyperpigmentation.

Conclusions: 
The discussion of sunscreen for people of color is limited on TikTok. Of the top posts, few contained educational information and the majority were created by dermatologists. Given the popularity of TikTok and its use to promote other sources of health information, there is room to improve the outreach related to sunscreen on the popular social media platform. 


Analysis of Sunscreen-Related Posts Directed Toward People of Color (POC) on TikTok

Background 

Early melanoma detection has profound clinical impact with distant stages having a
32% 5-year relative survival rate. Traditionally, the automation of melanoma detection prior to biopsy has relied on broad-spectrum photography, thresholding in the frequency domain or analysis of electrical impedance. The advent of deep learning (DL) has enabled automation of dermoscopy.
However, most existing end-to-end DL approaches require annotated data, which is time-consuming to produce and cannot propose novel predictive markers. To address this, we utilized the Semantic Clustering by Adopting Nearest Neighbors (SCAN) algorithm, an unsupervised learning approach that decouples feature learning and clustering, enabling the automated detection of dermatoscopic features that predict disease.

Methods 

We employed the SCAN algorithm to analyze 7991 training and 2024 testing
dermatoscopic images of melanoma or benign nevi from the International Skin Imaging Collaboration dataset. Images are almost all Fitzpatrick type I-III. The model was trained to learn semantically meaningful features that were employed to build clusters of similar images.

Results 

The final clusters exhibited varying levels of homogeneity, with several clusters composed exclusively of one class (melanoma/benign nevi). Several highly predictive clusters for melanoma showed an absence of color uniformity, which is a Menzies method criterion to establish melanoma diagnosis. This indicates latent-space morphology congruent with established evidence-based practice.

Conclusion 

The application of the SCAN algorithm to dermatoscopic images presents a promising methodology for unsupervised learning in melanoma detection. Previous work has shown that AI models that offer explanations to clinicians, such as photos of similar lesions in that continuous area of the model’s latent space, boost physician satisfaction. The FDA approval process also prefers explainable paradigms to ensure model predictability spanning the input space. This study presents an unsupervised approach to melanoma detection via dermoscopy, which enables explainable AI and automated detection of features that predict disease. By providing explainability, the research addresses a key challenge in machine learning paradigms’ FDA approval pathway. Future research is warranted to see if analysis of nevi on dark skin (Fitzpatrick type >3) demonstrates alternate dermoscopic features, as has been previously reported in dermoscopic
literature.

End-to-End Semantic Clustering in Dermoscopy of Melanocytic Lesions

Alopecia areata (AA) is an autoimmune condition that leads to patchy, nonscarring hair loss. The etiology still remains unknown, and the condition can be debilitating for patients, impacting their psychosocial wellbeing. Various triggers have been reported ranging from genetic predispositions, infections, and environmental factors. Medications have also been thought to be an inciting factor in AA. Using the FDA adverse event reporting system (FAERS), all cases reporting AA as an adverse event were used to capture associated medications and patient characteristics. Descriptive statistics were conducted along with logistic regression analysis using patient sex as the primary outcome. There were 1,331 AA cases reported as an adverse event with medication use. With regards to the top 10 medications, 29.2% of AA cases were seen with docetaxel, 8.3% were with adalimumab, 4.7% with trastuzumab, 4.4% with cyclophosphamide, 4.3% with infliximab, 4.1% with carboplatin, 3.4% with dupilumab, 2.7% with levonorgestrel, 2.6% with etanercept, and 2.6% with from pertuzumab. Monoclonal antibodies accounted for 6 out of the top 10 drugs with the highest number of AA cases. Males were more likely to report AA when taking adalimumab (OR 1.79, p = 0.04) and dupilumab (OR 2.56, p = 0.03) compared to females. Individuals between 42-64 years old accounted for 46.7% of AA cases. Lastly, females in older age groups showed greater odds of experiencing AA compared to males (OR 1.03, p < 0.01). Based on the FAERS, there has been a steady rise in AA cases and monoclonal antibodies were the most frequently cited medication class tied to AA. Given the dearth of literature and many unanswered questions surrounding AA, our novel large dataset study highlights the most associated medications, identifies an increase in reported cases over the years, and captures age/sex related demographic trends. An awareness of notable medications and patient demographics adds granularity to the spectrum of potential AA triggers and may increase a provider’s index of suspicion to improve clinical outcomes in the future.

A Cross-Sectional Analysis of Medications Used by Patients Reporting Alopecia Areata on the FDA Adverse Event Reporting System

Objective: To determine the effect of video and direct laryngoscopy on first-pass success rates for out-of-hospital orotracheal intubation.
Methods: MEDLINE, Embase, and Cochrane databases were searched from inception to January 2023. Out-of-hospital studies comparing video and direct laryngoscopy on either first-pass or overall intubation success were included. A random effects meta-analysis was performed with a primary outcome of first-pass success stratified by clinician type and laryngoscope blade geometry. The secondary outcomes were overall intubation success stratified by clinician type, and intubation time. All hypotheses and subgroup analyses were determined a priori.
Results: Twenty-five studies involving 35,489 intubations met inclusion criteria. Substantial heterogeneity (>75%) precluded reporting point estimates for nearly all analyses. For our primary outcome, video laryngoscopy was associated with improved first-pass success in 3/5 physician studies, 4/6 critical care paramedic/registered nurse studies, and 7/10 paramedic studies. Video laryngoscope devices with Macintosh blade geometry were associated with improved first-pass success in 7/10 studies, while devices with hyperangulated geometry were associated with improved first-pass success in 3/7 studies. Overall intubation success was greater with video laryngoscopy in 2/6 studies in the physician subgroup and 9/10 studies in the paramedic subgroup. Video laryngoscopy was not associated with overall intubation success among critical care paramedics/nurses (OR = 1.89, 0.96 to 3.72, I2 = 34%). Lastly, 4/5 studies found video laryngoscopy to be associated with longer intubation times.
Conclusions: We found substantial heterogeneity among out-of-hospital studies comparing video laryngoscopy to direct laryngoscopy on first-pass success, overall success, or intubation time. This heterogeneity was not explained with stratification by study design, clinician type, video laryngoscope blade geometry, or leave-one-out meta-analysis. A majority of studies showed that video laryngoscopy was associated with improved first pass success in all subgroups, but only for paramedics and not physicians when looking at overall success. This improvement was more common in studies that used Macintosh blades than those that used hyperangulated blades. Future research should explore the heterogeneity identified in our analysis with an emphasis on differences in training, clinical milieu, and specific video laryngoscope devices.


Out-of-Hospital Video Laryngoscopy: Should We Be Convinced?
A Systematic Review & Meta-Analysis

Background:
As we navigate the post-COVID era, it is essential to confront the health challenges that arose from our changed lifestyles. The World Health Organization (WHO) predicts that by 2025, one out of five adults globally will be obese. Researchers have identified a connection between obesity and mild cognitive impairment. Cognitive impairment is a major public health issue with rising costs for governments and communities. This study aims to evaluate the impact of obesity on cognitive function 

Methods:
A systematic review was undertaken, following the PRISMA 2020 guidelines. Initially, 1250 potentially eligible studies were discovered, out of which 12 duplicates were removed. A thorough assessment of titles and abstracts, 35 full-text articles carefully reviewed, and ultimately, 21 eligible studies incorporated. The search encompassed databases such as PubMed, ScienceDirect, and Google Scholar, focusing on the most recent 20-year period. Articles involving animal models were omitted, and only those freely available in the English Language were examined for inclusion.

Results: 
Based on the literature reviewed, obesity is significantly associated with an increased risk of cognitive impairment in younger and middle-aged individuals but not in older age. Older people with obesity may have a reduced risk of incident dementia. Studies show that obese individuals aged ≥65 years had lower risk ratios for incident dementia compared to normal-weight individuals (0.83 and 0.88, respectively). Another study indicates lower cognitive function in obese school children compared to healthy ones. 

Conclusion:
Obesity is a complex, multifactorial, but preventable disease. Evidence indicates that obesity is associated with cognitive impairment, increasing the risk of dementia later in life. Pathophysiological mechanisms, such as neural integrity reduction and inflammation, contribute to cognitive decline. Addressing obesity through public health interventions may help prevent cognitive impairment. More research is needed to understand the association fully, especially regarding body weight and dementia risk in older age. The lack of a universally accepted cognitive test approach hinders early detection of mild cognitive impairment.


Investigating Obesity-Related Cognitive Decline

Background
Type 2 diabetes mellitus (T2DM) may be a long-term sequela of Mycobacterium tuberculosis (M.tb) infection by mechanisms yet to be fully unraveled. Using the 2011-2012 NHANES, we evaluated (i) the association between latent tuberculosis infection (LTBI) and T2DM among adults (≥20 years old), and (ii) the extent to which this association is mediated by insulin resistance and β-cell failure.

Methods
T2DM was assessed by fasting plasma glucose and HbA1c; homoeostasis model assessment 2 (HOMA2) was used to estimate β-cell function (HOMA2-B) and insulin resistance (HOMA2-IR); while LTBI status was ascertained by interferon-γ release assay. Quintile and probit regression models were used to examine associations between LTBI and, respectively, HOMA2 indices, and prevalent T2DM. Mediation analyses using the counterfactual framework were then performed to quantify the contribution of each of β-cell dysfunction and insulin resistance to the association of LTBI with T2DM. Analyses were adjusted for sociodemographic, behavioral and clinical confounders.

Results
The analytic sample included 2,235 adults. Compared to TB uninfected individuals, those with LTBI were older [median (IQR): 60 (46, 69) vs. 44 (30, 61) years old], and more frequently male [58.5% vs. 48.9%]. LTBI was associated with increased insulin resistance [adjusted mean difference (AMD) (95% CI) in median: 0.08 (0.01, 0.22); p=0.048] but not β-cell function [AMD in median: -2.6 (-9.4, 4.3); p=0.46]. Similarly, T2DM was more prevalent among those with LTBI [adjusted prevalence (95% CI): 18.3 (13.1, 23.5)%] than peers without TB [11.2 (9.7, 12.9)%], corresponding to an adjusted absolute risk difference of 7.4 (2.3, 13.4)%. In mediation analyses, insulin resistance and β-cell function mediated 22.7 (12.2, 68.9)% and 2.7 (-1.4, 9.7)%, respectively, of the total effect of the association between LTBI and T2DM.

Conclusion
Definitive prospective studies examining incident T2DM following tuberculosis are warranted. Notwithstanding, our findings suggest infection with M.tb may be a novel risk factor for T2DM, likely driven by an increase in insulin resistance.

Insulin resistance, and not β-cell impairment, mediates association between latent tuberculosis infection and type II diabetes mellitus among US adults.

Background
There is a higher burden of diabetes related lower extremity amputation in the Lower Rio Grande Valley area of Texas compared to the Texas average. Hispanics have a higher proportion of this complication in the region. Yet, there is a dearth of research on factors associated with the risk of diabetes associated amputation in Hispanic populations. This study evaluates factors associated with diabetic related amputations in Hispanic patients with diabetic foot ulcer in the Rio Grande Valley area of Texas.

Methods
Our study was a retrospective study using patients’ medical records. Subjects were categorized based on whether they had at least one amputation (outcome) during the period of analyses. Baseline demographic, lifestyle, and metabolic characteristics of participants were determined. Characteristics of interest were insulin use, neuropathy, nephropathy, peripheral arterial disease, hypertension, history of cerebrovascular accident, smoking status, osteomyelitis, previous history of diabetic foot ulcer, previous history of amputation, hyperlipidemia, and glycated hemoglobin levels. Chi-square tests were used to analyze the association between these characteristics and amputation status. Logistic regression modeling was used to estimate the odds ratios for amputation and their 95% confidence intervals by each of the independent variables. We adjusted for age and gender in our multivariable analyses. Statistical analyses were carried out using Stata software.

Results
This study included 120 subjects, all of whom had diabetic foot ulcer. Sixty (50%) of the study subjects had diabetic foot amputation and the rest did not. The variables found to be significantly associated with amputation were peripheral arterial disease (p = 0.006), osteomyelitis (p < 0.0001), previous history of amputation (p < 0.0001), and hyperlipidemia (p = 0.013). However, previous diabetic ulcer, neuropathy, nephropathy, hypertension, smoking status, the use of insulin, retinopathy, and levels of hemoglobin A1c were not significantly associated with amputation.

Conclusion
Diabetic foot amputations have untold effects on the lives of affected individuals, and the broader society. Thus, factors promoting this event should be readily prevented and managed. In the studied population, peripheral arterial disease, osteomyelitis, previous amputation, and hyperlipidemia were significantly linked to diabetic foot amputations. Hence, while more research is required, medical professionals should actively seek out and adequately manage diabetic Hispanic patients with these risk factors to prevent this complication.

Factors associated with diabetic foot amputations in Hispanic patients in Rio Grande Valley, Texas.

Background
The bi-directional relationship between depression and prescription opioids is well-established. Evidence shows that adults with depression and non-cancer pain are more likely to remain on opioids and are at risk for opioid use disorder. In contrast, less is known about persistent opioid use and change in anxiety. Among chronic pain patients, opioid users are at higher risk for developing anxiety symptoms compared to those receiving other forms of pain management. However, it is unknown if continued use leads to worsening anxiety when compared to quitting. This study aims to determine if persistent opioid use is a risk factor for developing or worsening generalized anxiety disorder (GAD).

Methods
This prospective cohort study involved non-cancer pain patients (n=361) 18-70 years old starting a period of 30 to 90-day opioid use. Patients from Saint Louis University’s medical practice and the Henry Ford Health System self-administered web surveys or participated in telephone interviews. Difference in difference (D.I.D) analysis determined if change in opioid use was associated with change in GAD-7 scores. Outcome measures included mean GAD-7 score, change in GAD-7 score between baseline and 6 months, and threshold change from a GAD-7 score<10 before and after adjusting for age, race, gender, depression, PTSD, anhedonia, substance use disorder, smoking, and alcohol use.

Results
At baseline, those who persistently used opioids had significantly higher GAD scores [6.4 (±5.9)] compared to those who quit [4.7 (±5.3)]. However, there was no significant difference in GAD score at 6 months between persistent users [5.3 (±5.5)] and quitters [5.2 (±5.8)]. The crude D-I-D analysis revealed no differences in GAD score change from baseline to 6 months between the groups (D.I.D = -1.58; 95% CI: -3.38, -0.23). An adjusted analysis revealed similarly insignificant results (D.I.D = -1.16; 95% CI: -2.94,0.62). Furthermore, among patients with negative GAD (score<10) at baseline, there was no significant difference in risk of GAD (score>=10) at 6 months, whether they persisted or not [crude RR = 1.10; 95% CI: 0.55,2.20); adjusted RR = 1.01 95% CI: 0.53,1.93)].

Conclusion
Patients who persisted vs. quit opioid use at 6 months did not differ in association with worsening or new-onset GAD. However, the results reveal a trend for persistent opioid users to have lower 6-month GAD scores. Additional analysis with a larger sample is needed to determine the characteristics of patients who persist yet experience a decrease in GAD symptoms compared to those who experience constant or worsening GAD.

Persistent Opioid Use and the Development of Generalized Anxiety Disorder

Background
Crohn’s disease (CD) and ulcerative colitis (UC) are inflammatory disorders of the GI tract that may cause symptoms leading to the alteration of dietary intake to control symptoms. There are recommended diets for treatment of inflammatory bowel disease (IBD), but many diets have low-quality evidence for efficacy. However, in an effort to relieve symptoms, patients or families may self-restrict certain foods, leading to the development of restrictive eating behaviors.
In 2013, avoidant-restrictive food intake disorder (ARFID) was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to identify patients who actively restrict food intake leading to insufficient caloric/nutritional intake and causing at least one of the following complications: weight loss, nutritional deficiency, dependence on nutritional supplements, or psychosocial impairment. 
As ARFID is a relatively new diagnosis, the prevalence of this diagnosis in chronic disease states has not been well-characterized. A recent adult study measured the prevalence of ARFID in an adult IBD population, examined nutritional risk in the context of ARFID risk, and identified risk factors for ARFID in IBD patients. 28/161 (17%) patients had a positive ARFID risk score, as measured by the Nine-item ARFID Screening tool (NIAS).
Currently, there are no studies evaluating the prevalence of ARFID in pediatric patients with IBD. We estimate that the prevalence is high based on anecdotal food avoidances, particularly during a flare of symptoms. We also hypothesize that patients who have high ARFID risk scores may be more at risk for nutrition deficiencies. 
Methods
This is a prospective, observational cohort study of pediatric patients (age 0-17) with inflammatory bowel disease. Fifty patients will be enrolled. Participants complete surveys about eating behaviors and nutritional status after scheduled clinic visits. Study outcomes measured are ARFID risk score (calculated by the NIAS) and nutritional status (height and weight velocity z-scores, mid-upper arm circumference z-scores). 
Results
Based on recent guidelines, a positive ARFID risk score is defined as a score that meets at least one of the following criteria: ≥10 in the picky eating sub-score, ≥9 in the appetite sub-score, ≥10 in the fear sub-score, ≥24 in the total NIAS score Preliminary results suggest a prevalence of ARFID in participants based off a positive ARFID screen to be 21% (8/38 patients), compared to the estimated prevalence of ARFID in community pediatric populations of 2%.
Conclusion
We anticipate that the results of this study can help clinicians address nutritional deficiencies in pediatric IBD patients before it becomes detrimental to patients’ well-being. With the knowledge that pediatric IBD patients are more at risk of ARFID, their needs can be predicted by clinicians and dietitians to ensure proper care of patients.

Evaluating the Prevalence of Avoidant Restrictive Food Intake Disorder in Pediatric Patients with Inflammatory Bowel Disease

Background
Routine hepatic ultrasonography is the most used clinical imaging study in diagnosing chronic liver diseases (CLDs), including assessing hepatic steatosis, a common presentation of CLDs. However, data remain lacking on the performance of hepatic ultrasonography in assessing steatosis and factors that may impact the quality of its performance. This study evaluated the association of hepatic ultrasonography for the assessment of hepatic steatosis with histological hepatic steatosis and other related factors.
Methods
A single-center retrospective study of 188 patients with various CLDs, regular follow-ups, and liver biopsy at the UCIMC Liver Clinic.
Results
The mean age±SD was 57±13 years old. 93 patients were male (49.5%), and 44 (23.4%) had a BMI ≥ 30. Chronic hepatitis C (CHC, 20.8%) and B (17.5%), and non-alcoholic fatty liver disease (NAFLD, 29.0%) were the main CLDs. In this cohort, 89/187 (47.6%) patients had biopsy-proven hepatic steatosis (i.e., ≥ 5% of hepatocytes), 129/188 (68.6%) had ultrasonographic reports of hepatic steatosis, and 67/184 (36.4%) had ultrasonographic reports of hepatomegaly (i.e., ≥ 16.5 cm). The sensitivity and specificity of hepatic ultrasonography for assessing hepatic steatosis, compared to histological steatosis ≥ 5% (gold standard), was 85.4% (76/89 patients) and 46.9% (46/98 patients), respectively. Chi-square analysis showed that hepatic steatosis on ultrasonography was significantly associated with biopsy-proven hepatic steatosis (76/128, 59.4%, p<.01). Hepatic steatosis on ultrasonography was also significantly associated with age ≥ 65 years old (48/129, 37.2%, p=.02), histological evidence of ballooning degeneration (57/86, 66.3%, p<.01), Mallory-Denk bodies (20/60, 33.3%, p<.01), and portal/periportal fibrosis (66/98, 67.3%, p<.03). The frequency of hepatic steatosis diagnosed on ultrasonography was higher in those with NAFLD (45/92, 48.9%) than those with CHC (25/92, 27.2%) or CHB (22/92, 23.9%), but the difference was not significant (p=.08). Ultrasonographic-diagnosed hepatic steatosis was not significantly associated with BMI ≥ 30 (31/129, 24%, p=.76), elevated AST or ALT to ≥ 35 IU/L for males or ≥ 25 IU/L for females (90/111, 81.1%, p=.06 or 84/111, 75.7%, p=.77, respectively). In multivariate analysis, ultrasonographic-diagnosed hepatic steatosis was significantly associated with the presence of ballooning degeneration (95% CI: 1.25-20.72; p=.02) and portal/periportal fibrosis (95% CI: 1.29-11.14; p=.02) on liver biopsy, but not biopsy-proven hepatic steatosis (95% CI: 0.17-1.94; p=.37) or hepatomegaly on ultrasonography (95% CI: 0.71-7.33; p=.17).
Conclusion
Routine hepatic ultrasonography has good sensitivity, but low specificity in the assessment of hepatic steatosis. Histological hepatocytic ballooning degeneration and portal/periportal fibrosis were independently associated with hepatic steatosis detected by ultrasonography.

Next from AMA Research Challenge 2023

Analysis of Sunscreen-Related Posts Directed Toward People of Color (POC) on TikTok