United States

Instagram is the most downloaded app globally, with billions of active users. Instagram has evolved to encompass several categories of posts, including advertisements. Users below the age of 24 make up 38.6% of total Instagram users, and the United States Preventive Services Task Force recommends counseling patients about decreasing the risk of skin cancer by minimizing exposure to ultraviolet radiations, especially for ages 6 months to 24 years. Users are more likely to connect with advertisements in which they feel represented; therefore, it is important that the sun protection (SP) advertisements on the application are inclusive of all races and genders. The purpose of our study was to analyze the quality of advertisements on the Instagram profiles of common SP brands. The thirty most recent product-related posts on Instagram profiles of common SP brands were analyzed. Results revealed Fitzpatrick skin types IV-VI are poorly represented in the Instagram posts of SP brands, totaling only 35.5% of featured people. Additionally, only 19% of the total posts including males. There is a documented misconception amongst people of color that the use of SP to prevent skin cancer and photoaging is unnecessary. Additionally, there is a greater incidence of skin cancer in males, which may be attributed to less SP use than females. With advertisements expanding to easily accessible applications like Instagram, it would be beneficial to determine avenues to improve representation within these advertisements to promote patient compliance with SP products.

AMA Research Challenge 2023

Instagram Advertisements for Sun Protection Products: A Spectrum to be Broadened

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Background
Psoriasis is a multisystem inflammatory disease associated with increased cardiovascular risk. Prior studies have shown a paradoxically lower mortality in AMI (acute myocardial infarction) despite higher comorbidities in psoriasis patients. The lower age of AMI patients with psoriasis may explain this paradox. Our study looked for possible additional explanations.

Methods
The Nationwide Inpatient Sample (NIS) is the largest US inpatient database cataloging over 7 million hospitalizations annually. This retrospective study analyzed this database from January 2016 to December 2019. Appropriate ICD-10 codes identified both AMI patients and AMI- psoriasis subset. Chi–square testing and multivariable binary logistic regression were used for analysis.

Results
Amongst 2.55 million AMI patients, 15,520 had psoriasis in addition. At baseline, AMI patients with psoriasis had significantly higher rates of smoking (31% vs 25%), alcohol use (1.39% vs 1%), diabetes (43% vs 41%), hypertension (47% vs 44%), dyslipidemia (71% vs 66%), prior CAD (83% vs 80%), COPD (25% vs 22%) and thyroid disease (14% vs 13%). Psoriasis patients had significantly lower age (64.9 vs 66.9 years).

A higher percentage of AMI patients with psoriasis were White compared to AMI patients without psoriasis (80% to 71%); and the converse for African Americans (4% to 11%). These racial differences were statistically significant.

Comparing outcomes, psoriasis patients had significantly higher rates of CABG (11% vs 7%), length of stay (4.5 versus 4.4 days) and hospital costs ($ 103,247 vs $ 99,094). Notably, psoriasis patients had significantly lower in-hospital mortality (2.74% vs 4.93%). The adjusted odds ratio was 0.70 (95% CI 0.56- 0.88). The p-values for all above-mentioned metrics were between 0.00 and 0.02.

Conclusion
A possible explanation for this mortality paradox was the lower age of incidence for AMI in patients with psoriasis (68 years versus 73 years in a 2020 German study). In our dataset, the difference in mean age of incidence between the two groups was only 2 years (64.9 years versus 66.9 years). One striking confound between the two groups is racial demographics. The data shows a statistically significant increase in percentage of white psoriasis patients having AMI than minority groups. If healthcare access/standard of care is different for these two groups, then this would provide an explanation for this paradox and show that this is not pathological issue but rather a sociological one. With growing concerns about equal opportunity access to healthcare, this paradox warrants further study and has potential to demonstrate opportunities for improvement.


Racial Differences May Explain The Psoriasis Mortality Paradox in Acute Myocardial Infarction: A Nationwide Inpatient Sample Analysis

Background. Dermatillomania (skin picking disorder) is a psychodermatologic disorder consisting of compulsive picking leading to chronic mechanical damage to skin integrity. Secondary to this damage come possibilities of infection and poor mental health as recurring open wounds and visible scabs form triggers in individuals with this condition. Likely to be largely under-reported, the American Journal of Psychiatry estimates that dermatillomania occurs in upwards of 1 in 20 patients. A trending nutraceutical, N-acetyl cysteine (NAC), shows promise as it encourages rapid regeneration of tissue without scarring. As a cysteine donor, NAC replenishes glutathione reductase, which serves as a safeguard against reactive oxygen species (ROS), thereby averting further cellular damage. Whether utilized as a high-dose systemic therapy or applied topically, NAC exhibits a large therapeutic index providing patients with a safe and potentially effective nutraceutical treatment option. Moreover, a comprehensive biopsychosocial approach can be provided through the social cognitive theory (SCT) framework which bolsters the self-efficacy and behavioral capacity of an individual to form positive health behaviors. Improving SCT constructs like reciprocal determinism, individuals’ perceptions, social interactions (family/peers), and environmental factors (stressors, UV radiation), will provide better patient support. 

Methods. A preliminary search was performed on all freely available PubMed articles from the past decade that discussed “n-acetyl cysteine wound healing”. A total of 76 articles were acquired. Articles that did not fall under the topics of dermatology, plastic surgery, medical treatments or did not review the use of NAC directly were omitted from our study. Finally, 19 articles detailing NAC’s effectiveness in reducing wound margins and scarring were identified for use in this study. 

Results. Findings show the pro-wound healing properties of NAC, including its ability to promote re-epithelialization, cell proliferation, enhance angiogenesis, and inhibit fibroblast migration. Moreover, NAC boosts antioxidant enzymes (glutathione reductase and superoxide dismutase) to slow ROS-mediated DNA damage. 

Conclusion. By eliminating "pick-able" scabs and accelerating healing, NAC may reduce triggers for patients with dermatillomania and associated risk of infection for other skin excoriations. Therefore, we recommend the integration of NAC as an essential treatment for this specific population as it can abate triggers that exacerbate skin injury and infection in patients with dermatillomania. Furthermore, integrating the SCT framework to deliver psychosocial support may bolster patients’ self-esteem, reducing associated costs to treat future exacerbations and related complications. We have created SCAR-PROOF: a novel, multi-pronged biopsychosocial intervention aimed at supporting dermatillomania management and recovery for our target patient population.

SCAR-PROOF: A Novel Social Cognitive Approach to Prevent Skin Injury & Infection for Dermatillomania

Background: Windham Aging was created to analyze, primarily, ways for senior residents to age in place; a November 2022 report concluded that one of the barriers is lack of primary care professionals. The current physician workforce is aging into retirement with 48% of PCPs in Windham County being over 60 years old. Previous literature reported the following themes among primary care professionals as factors in determining retention and recruitment: financial, social, lifestyle, and community. 

Methods: This research study aimed to identify strategies to enhance the recruitment of primary care professionals in rural areas of Vermont. The study team conducted interviews with family medicine residents and Doctor of Nursing Practice (DNP) students. Using a qualitative, inductive approach, the team identified key themes that could impact the recruitment of primary care professionals in rural Vermont, including a 5-point scale on previously identified factors affecting recruitment. 

Results: Trainees (n=13) ranked housing, political association, community factors, and access to schools as most important. Qualitative analysis revealed that trainees’ financial incentives weigh less heavily than previous rural clinical experience and interest in living in a rural setting. 

Conclusion: Recruitment of rural practitioners in Vermont is largely influenced by personal preferences regarding community attributes and exposure to rural clinical training experience.

Recruitment of Primary Care Professionals in Rural VT

Background: Chronic disease appointment deferral was a potent problem throughout the pandemic. Additionally, literature shows poorer health for non-English-speaking patients. This study aims to bridge the existing gap in research for this patient population while assessing the state of primary care during the pandemic via chronic disease appointments.
Methods: The Larry A. Green Center launched a series of national surveys (n > 500) with a unique series of questions to obtain temporal, pressing information surrounding primary care’s response to the pandemic. We analyzed changes based on clinic perception of chronic disease appointment incidence using two of these surveys. We further stratified the data by the proportion of non-English speaking patients in each clinic and used Chi-square analysis to analyze significance.
Results: In October 2021, clinics with less English-speaking patients had a greater decrease in stable chronic disease appointments and a larger increase in unstable chronic disease appointments: Among clinics reporting ≥ 90% English speakers (n = 336), 36% (n = 121, p = 0.03) reported less stable chronic disease visits, and 30% (n = 99, p =0.01) reported more visits for unstable chronic disease. In clinics with ≤ 80% English-speaking patients (n = 239), 47% (n = 110, p = 0.03) reported a decrease in stable chronic disease appointments, and 40% (n = 97, p = 0.01) reported an increase in unstable chronic disease appointments. 
In March 2023, the clinics with the least English-speaking patients had a higher incidence of reporting a detrimental change in the stability of their patients’ chronic conditions: 32% (n = 273) of all total clinics, 29% (n = 125) of clinics with ≥ 90% English-speaking patients, 39% (n = 74) of clinics with 81 to 90% English-speaking patients, 42% (n = 48) of clinics with 50-80% English-speaking patients, and 49% (n = 26) of clinics with ≤ 50% English-speaking patients reported a transition from stable to unstable chronic disease due to lack of access to care (p = 0.001). 
Conclusion:
These findings suggest a clinician-reported transition of chronic conditions from stable to unstable, raising concern surrounding deferred care during the pandemic. This emphasizes the need for programs to improve accessibility to clinic visits. Furthermore, additional emphasis should be placed on clinics serving non-English speaking patients, as our study reveals higher rates of care deferral in this population.

Navigating the Deferral Dilemma: Understanding Access to Chronic Disease Care for Non-English Speakers and Overall

Background: Primary care physicians are the principal clinicians treating addiction medicine in the U.S., yet chronically lag behind the demand for substance abuse care. Current literature has detailed worsening substance abuse and addiction with the onset of COVID-19, especially among minority individuals. Our study works to understand low-income individuals from the perspective of primary care, for which current literature is lacking. 
Methods: The Larry Green Center gathered perception data surrounding many pandemic-related impacts on primary care using the weekly "Quick COVID-19 Primary Care" surveys. This study selected six nationwide surveys (n=582-1472) in 2020, 2021, & 2023. Each survey was selected based on their inclusion of addiction medicine questions and was analyzed using descriptive statistics. Surveys were stratified by income with significance testing via Chi-Square analysis (p<0.05). 
Results: Polled primary care clinics revealed an increased perception of addiction during all stages of COVID-19 compared to pre-pandemic levels. Three surveys in 2020 revealed that 31-39% of clinics reported more addiction. A marked increase occurred in December 2021 with 48% of clinics reporting more addiction. No data existed for 2022; however, 41% of clinics reported more addiction in March 2023, demonstrating persistent elevation. After stratification to income, roughly 26% of clinics reporting more addiction served 10-19% of low-income patients. This proportion was consistent for clinics with 20-49% low-income patients, which comprised approximately 25% of all clinics reporting more addiction. Clinics reporting more addiction over the fielded surveys were nearly twice as likely (~48%) to serve the highest proportion of low-income patients (>50% low income). All findings were significant at p<0.05. 
Conclusion: Perception data collected from primary care clinics during COVID-19 suggest a worsening addiction epidemic that disproportionately affected lower-income patients. Chronically underfunded primary care clinics need greater financial resources to tackle systemic stressors beyond COVID-19 that will continue to exacerbate the addiction epidemic in the U.S. Training primary care physicians in addiction medicine, eliminating barriers to addiction care, and targeting low-income patient populations may help to mitigate the current trend of addiction in the U.S.

Primary Care Offices Report More Substance Abuse Amidst COVID-19 - Expanding the Demographic Portrait

Background: The COVID-19 pandemic resulted in a national lockdown in Chile and delays in surgical care. This study aims to assess the effects of COVID-19 and Chile’s counteracting policies on surgical waitlist lengths a public hospital. 

Methods: Data on surgical waitlists at the closing of the year from 2016 to 2022 were obtained from Hospital La Florida. A one-way ANOVA with a Bonferroni correction was used to determine which years had a statistically significant difference in surgical waitlist times. The aggregate data for all surgical specialties was used to analyze which years had a statistically significant difference.

Results: There was a notable decrease in waitlist length each year from 2016 to 2019, with a statistically significant difference in waitlist length in 2016 and 2017 compared to 2019 (p = <0.001 and 0.023, respectively), and a nonsignificant difference in 2018 (p = 1.00). In 2020, there was a significant increase in waitlist length compared to 2019 (p = 0.001). The waitlist lengths returned to pre-pandemic levels after 2020, with no difference in waitlist lengths in 2021 and 2022 when compared to 2019 (p= 0.31 and 1.00, respectively).

Conclusion: The COVID-19 pandemic resulted in significantly increased surgical waitlists, with large improvements in waitlist lengths through Chile’s varied policies in resource management, budgeting, efficiency, and collaboration. Further work should assess which strategies were most successful in shortening surgical waitlists to continue removing the burden of surgical delays for patients.

The Impact and Health System Response of COVID-19 on Surgical Waitlists in Chile

**Scoring is only possible in the semifinals hall**

**Abstract:**



Correlating Sickle Cell Disease Across Seasonality and Geography

Many epidemiological studies have investigated the association between coffee consumption and risks for various types of cancer, yet results are conflicting. To determine the impact of coffee consumption on cancer incidence, we systematically reviewed high-quality prospective cohort studies for 10 major cancer types and performed meta-analyses of 63 studies from different countries. For each cancer type, we calculated summary relative risks using the DerSimonian–Laird random-effects model and assessed dose-response relationships. Our meta-analyses found that caffeinated coffee consumption, but not decaffeinated coffee, prevented liver and skin cancers, highlighting the significant role of caffeine in cancer prevention. Furthermore, both caffeinated and decaffeinated coffee prevented endometrial cancer, indicating the role of other active compounds in coffee. Collectively, our meta-analyses revealed that coffee consumption, particularly caffeinated coffee, prevents the incidence of liver, endometrial, and skin cancers in a dose-dependent manner, suggesting that coffee consumption has a large impact on public health.

Meta-Analyses of Prospective Studies on Cancer Incidence and Caffeinated or Decaffeinated Coffee

Our objectives were to examine whether there are racial differences in diffuse and anaplastic astrocytoma survivorship in children, and if so, to identify which racial groups have poorer survival.
Brain tumors represent the leading cause of cancer deaths in children. Moreover, 60% of these tumors are astrocytomas, neoplasms of the star-shaped glial cells, astrocytes, which provide physical support and aid in neurotransmission. Diffuse astrocytomas are indolent with low metastatic tendency and have survival ranges greater than 5 years. Anaplastic astrocytomas, however, represent a more aggressive neoplasm with greater metastatic potential and carry a survival range of 2-5 years. Both tumors are more common in adulthood, commonly reside in the frontal and temporal lobes, and are associated with few risk factors aside from ionizing radiation or genetic mutations such as p53. Current treatment of these cancers includes surgical resection, external-beam radiotherapy (EBRT), and adjuvant chemotherapy, dependent on location, histology, time since diagnosis, and other factors. Previous research supports an association between race and survival in children for brain malignancies generally; given racial disparities in healthcare delivery exist, we sought to bridge this gap to identify pitfalls in pediatric astrocytoma treatment due to its prevalence.
We analyzed 5-year relative survival rates in children under 15 with localized diffuse or anaplastic astrocytomas from 2000-2018 using the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program. The tumor classification used ICD-O-3 codes 9400-9401, 9410-9411, and 9420.
Racial groups included were Hispanic, Non-Hispanic Asian/Pacific Islander (NHAPI), Non-Hispanic Black (NHB), and Non-Hispanic White (NHW). Incidence for Hispanics and Non-Hispanics was based on the North American Association of Central Cancer Registries Hispanic Latino Identification Algorithm. Analysis of variance (ANOVA) and subsequent post- hoc two-sample T-tests were performed to assess associations between race and relative survival.
The ANOVA assuming that mean survival is equal across racial groups was statistically significant (p=3.9552-8) with an alpha level of 0.05. Post-hoc two-sample t-tests assuming unequal variances showed significantly different survival rates of NHAPI when compared to Hispanics, NHB, and NHW (p=0.01925, p=0.01888, p=0.00142, respectively where alpha=0.025).
Non-Hispanic Asians and Pacific Islanders have significantly worse survival compared to any other racial group. This varies from adult and pediatric research which associate lower survival in Black populations compared to White populations with the same brain tumor. These findings identify a unique racial difference not before described in the pediatric population and emphasize the need for closer inspection of neurooncological treatment practices.

Racial Differences in Pediatric Localized Diffuse and Anaplastic Astrocytoma Survival

Background
Racial disparities among cancer patients have become a national concern due to their effects on cancer prognosis. This study aims to address these disparities by examining the racial composition and potential inequalities among cancer patients treated at the Prisma Health Cancer Institute. The findings from this study are compared with national trends to provide insights into the impact of race on patient treatment outcomes. Factors such as cancer staging, histology, molecular characteristics, treatment, demographics, and lifestyle are analyzed to gain a comprehensive understanding of their impact on disease prognosis, treatment, and outcome.

Methods
The study includes 586 cancer patients diagnosed with breast (397) and lung (171) cancer between 2014 and 2022. Patients were categorized by race: Asian, African American, Hawaiian/Pacific Islander, Latino, Multi-Race, White, and patients with missing race information. The JMP software was used for statistical analysis of the racial composition in terms of diagnosis distribution, cancer staging, cancer histology, smoking status, cancer molecular subtypes, and other factors.

Results
In the studied group, African American males had a higher likelihood (3.17%) of breast cancer diagnosis compared to White males (0.84%). Additionally, the African American population showed a greater proportion of stage IV lung cancer (11.11%) compared to the White population (4.63%). Our data for breast cancer in males and stage IV lung cancer were similar to national trends, with African Americans having an increased probability of these characteristics. Notably, the incidence of triple-negative breast cancer was similar between African American (14.63%) and White (13.18%) females in the studied cohort, Our data differed from the national trend for triple-negative breast cancer, where African American females have a higher likelihood of the diagnosis.

Conclusion
This study provides a focused examination of patients treated at the Prisma Health Cancer Institute, shedding light on population differences in two highly lethal cancers. Our study combines multiple factors such as molecular, clinical, and demographic data to identify areas of disparity concerning cancer patients. The research aims to improve treatment and care for minority patients. The findings contribute to a better understanding of racial disparities in cancer outcomes, potentially leading to ethnicity-specific and minority-inclusive interventions. Moreover, this research has the potential to enhance physician-patient interactions and promote more equitable healthcare.

Next from AMA Research Challenge 2023

Racial Differences May Explain The Psoriasis Mortality Paradox in Acute Myocardial Infarction: A Nationwide Inpatient Sample Analysis