United States

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.

2023 AMA Research Challenge

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

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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.

Racial Composition Analysis Using Molecular, Clinical, and Demographic Data of Cancer Patients from the Prisma Health Cancer Institute

Background
The presence of wounds, from either acute or chronic circumstances, places a significant burden on a patient’s quality of life (QoL). In the US, as the number of patients with chronic health conditions such as diabetes mellitus, vascular disease, and obesity continues to rise, so does the risk of complications of wounds. Some of these complications include the increased risk of infection and further issues with tissue revascularization, both of which are associated with worse morbidity. The increasing patient population signifies the necessity for proper community education on wound care in the home and after in-office procedures to reduce the risk of further complications. Our study gathered community knowledge from a student-run free-dermatology clinic, according to AAD guidelines, to better assess community knowledge of wound care.

Methods
Using a 6-question paper survey with five multiple-choice questions and one 5-point Likert scale rating for confidence assessment of wound care knowledge (1 equating not confident and 5 equating very confident) was voluntarily answered by patients aged 18 years and older at a Free Student-Faculty Collaborative Dermatology Clinic. A quantitative analysis was run to interpret the 30 results. A one-tailed T-test was used to evaluate the responses to the multiple-choice questions under the assumption that getting three out of four questions indicated sufficient knowledge. 

Results
Although the average confidence from the responses was 4.33 using a Likert scale rating, further inquiry showed only 7.4% were using a method consistent with current AAD guidelines. Our results showed 51.85% of respondents were able to identify all the characteristics of an infected wound and 66.7% correctly chose the use of mild soap and water for washing. Only 23.1% of responses correctly identified that wounds need to be kept moist. Analyzing the multiple-choice questions, only 37.03% demonstrated sufficient knowledge of wound care (p<0.0005).

Conclusion
Our study demonstrated the importance of providing patients with standardized wound care education. Presently at our clinic, a wound care recommendation sheet in accordance with AAD recommendations is offered to patients who recieve biopsies or in-office procedures. The initiative was implemented to help close the education gap for patients regarding wound care. Clinics and providers can similarly provide materials or have posters in the office to highlight similar wound care recommendations. A limitation of this study was the small sample size and possible misinterpretation of the questions based on individual comprehension.

Wound Care Knowledge in the Community Setting: Closing the Patient Education Gap

Background
Neurological symptoms affect greater than one third of adult COVID-19 patients. As growing literature illustrates COVID-19 as both a pulmonary and a vascular disease, neurological sequelae are frequently noticed but still not fully understood. Elevated intracranial pressure (ICP) findings have been noted increasingly in COVID-19 patients and has been associated with higher mortality amongst COVID-19 ICU patients. Yet, there is a dearth of literature explaining these disease processes and providing providers with standardized clinical recommendations for detection and therapy. Through a standardized case series, our study aims to better characterize COVID-19 and elevated ICP findings in patients, report treatment modalities and their outcomes, and discuss potential therapies and areas for further inquiry.
Methods
In this retrospective case series, adult neurology patients who had both received a diagnosis of idiopathic intracranial hypertension (IIH) and had COVID-19 were interviewed using a standardized questionnaire that surveyed data regarding symptom types and length and treatment modalities. Qualitative analysis and review of patients' clinical and laboratory data were evaluated.
Results
Amongst eight patients interviewed, six successfully completed surveying and met all study criteria. The cohort comprises five females and one male and BMIs ranging from 35 to 51. The most common IIH symptoms included headache, vision changes or loss, tinnitus, dizziness, nausea, and auditory changes. Four had an IIH diagnosis before contracting COVID-19, and two had findings of IIH only after contracting COVID-19. Most patients who had an IIH diagnosis prior to contracting COVID-19 experienced vision changes or loss. No patients who had IIH only after COVID-19 reported symptomatic vision changes or loss. Patients with the preexisting IIH diagnosis also more commonly experienced headaches. All patients with prior IIH used acetazolamide. Three patients who had prior IIH diagnoses reported improvement with therapeutic lumbar puncture. All six patients had improvement of symptoms with treatment and over time.
Conclusion
Patients with IIH may be at increased risk for higher severity of COVID-19 neurological morbidity, specifically visual changes and headaches. Detection of papilledema in patients at risk for elevated ICP who contract COVID-19 may be an important step in detection of new IIH diagnosis and early treatment for worsening neurological and ophthalmic sequelae. Acetazolamide and therapeutic LP may present as useful tools to address ICP exacerbation in IIH and COVID-19 patients. Further study of COVID-19 and IIH therapy strategies is important for preventing vision loss and serious neurological damage.

Neurological Sequelae in Idiopathic Intracranial Hypertension and
COVID-19 Patients: A Novel Case Series

Endometrial cancer is the most common cancer of the female reproductive organs in the United States. Endometrial carcinomas encompass a variety of neoplasms with varying patient outcomes and prognoses. Given the higher incidence of endometrial cancer in the United States, it is important to examine the factors contributing to the worsened prognosis of a late vs. early-stage diagnosis. 


Demographics in Early vs. Late-Stage Endometrial Cancer: A NCBD Review


Background
In 1960, childbearing education classes (CEC) were created to educate women about the labor and delivery process. Women who attended CEC have higher rates of vaginal deliveries versus cesarean delivery. Other benefits of CEC are increased confidence, increased likelihood of breastfeeding, better communication between the patient and their care team, a decrease in analgesic use, and increased labor and delivery satisfaction. Knowledge is powerful in situations of the unknown. Demographics of women who attend CEC are most commonly white, have a college degree, and are considered above the poverty line. One theory behind these findings is the lack of availability of CEC to women of lower education and lower socioeconomic status. 
Methods
We created a list of counties in South Dakota and their respective clinics and hospitals and contacted each location to see if they offer CEC. If they did not, we asked for a referral location. We wanted to create a map showing each CEC offered in South Dakota and map out the distance between each CEC and estimate how big of a radius each CEC covers.
Results
There are only 17 CECs held in the state of South Dakota. 13 CECs are offered full-time and four are offered on a periodic or individual basis. We found the average distance between each CEC to be 50.49 miles. Our results showed a greater disparity than we originally anticipated. 
Conclusion
CEC is lacking in South Dakota, especially in rural areas. South Dakota has the highest birth rate per 1,000 people in the United States, creating a need for CEC and education before delivery. This information shows the disparity in South Dakota and can serve as a reference point for other rural areas to bring attention to the importance of CEC and geographic obstacles.

Childbearing Education Classes in South Dakota

Background
The COVID-19 pandemic resulted in changes to healthcare delivery for peripartum patients. Hospital location and population have been shown to be factors that can influence birth outcomes. The purpose of this study was to examine the impact of the COVID-19 pandemic on adverse birth outcomes between urban and suburban hospitals.

Methods
This retrospective cohort study compared gestational age and birth weights of 650 non-COVID infected pregnant patients, 400 of whom were seen at an Level III urban perinatal medical center in New York City and 250 of whom were seen at its affiliated Level IV suburban perinatal medical center approximately 25 miles away during the pandemic (August 2020 to February 2021) and the corresponding pre-pandemic period (August 2019 to February 2020) using student t-test, Mann-Whitney, and chi-squared tests.

Results
The COVID-19 pandemic was not a statistically significant predictor for preterm births (OR 1.078 95%Cl 0.644-1.804 p< 0.776) or low birth weights (OR 1.307 95%Cl 0.770-2.218 p<0.321) for patients giving birth at either an urban or suburban hospitals. Giving birth at an urban hospital was associated with a reduced likelihood of preterm birth (OR 0.241 95%Cl 0.141-0.411 p<0.001) and low birth weights (OR 0.289 95%Cl 0.170-0.492 p<0.001) during the study period. Patient’s race, insurance status, or delivery method were not statistically significant predictors of low birth weight or preterm births.

Conclusion
In this principal study of the influence of the pandemic upon adverse birth outcomes, we find that the stresses associated with the COVID-19 pandemic did not influence the likelihood of preterm birth or low birth weight. Our results verify the existence of an urban-suburban disparity in birth outcomes, with urban centers caring for pregnancies associated with preterm birth and low birth weight but suggest that the pandemic did not exacerbate this existent disparity.

Evaluating the Influence of the COVID-19 Pandemic on Adverse Birth Outcomes

Background
The under-reporting of subject demographics and race disparities in ophthalmic clinical trials have been documented in the past. The Final Rule for Clinical Trials Registration and Results Information Submission conditionally requires race and ethnicity disclosure for studies whose primary completion date is on or after January 18, 2017. We examined the change in the enrollment and demographic disclosure rate among US-based ophthalmic clinical trials after the implementation of the Final Rule.

Methods
ClinicalTrials.gov was queried for “eye,” “eye diseases,” and “ocular.” US-based trials with a completed status and enrollment greater than or equal to 50 subjects were included (n=872). Trials with a primary completion date on or after 1/18/2017, and results first submitted on or after 4/18/2017 (Final Rule compliance date) were categorized as “post-requirement” (n=314) trials. Trials prior to these dates were categorized as “pre-requirement” (n=558) trials. Primary outcomes included the disclosure rate and enrollment of each race/ethnicity category. The disclosure rate before and after the implementation of the Final Rule was compared with Pearson’s chi-square test. The enrollment before and after the implementation of the Final Rule was compared with the Mann-Whitney U-test.

Results
The race disclosure rate, as defined by the proportion of studies disclosing any race information, significantly increased (p<0.0001) among post-requirement trials (84.39%) compared to pre-requirement trials (26.16%). The ethnicity disclosure rate, as defined by the proportion of studies disclosing any ethnicity information, significantly increased (p<0.0001) among post-requirement trials (55.73%) compared to pre-requirement trials (16.85%). The disclosure rate of all race/ethnicity categories increased significantly among post-requirement trials (p<0.0001) compared to pre-requirement trials. There was no significant change in enrollment of any race/ethnicity category between all pre- and post-requirement trials. White subject enrollment was higher and Hispanic subject enrollment was lower in non-NIH-funded trials versus NIH-funded trials both before (White subjects, p=0.0022; Hispanic/Latino subjects, p=0.0495) and after (White subjects, p=0.0002; Hispanic/Latino subjects, p=0.0168) the implementation of the Final Rule.

Conclusion
While the disclosure rate of race in clinical trials approximately increased by a factor of 3, the enrollment of minorities demonstrated no change after the implementation of the Final Rule. White subject enrollment was higher, and Hispanic subject enrollment was lower in non-NIH-funded trials compared to NIH-funded trials after the implementation of the Final Rule, which has not been previously reported. Stronger legislation that requires the enrollment of minority groups and subsequent demographic information reporting is needed to improve diversity in ophthalmic clinical trials.

Demographic Disclosure Rate and Enrollment Before and After the Final Rule in Ophthalmic Clinical Trials

Background
Performing ptosis surgery in an office-based setting is less costly to the health system relative to an operating room. However, 90% of US ptosis surgeries are performed in the less economical operating room. This study aims to understand the financial and practical factors involved in surgical location decision-making, and the modifiable incentives to influence migration from operating room to procedure room.

Design
Economic analysis 

Methods
Oculoplastic surgeons were surveyed to determine the most important attributes when deciding to perform a surgery in an operating room (OR) or office procedure room (PR). Responses were collated and common themes extracted. Consensus themes were operationalized into major domains: reimbursement, comorbidities, sedation requirements, and logistics. Reimbursement consisted of five levels starting at $550, with each level increasing by 50%, until total reimbursement tripled at $1650. Comorbidities, sedation requirements, and logistics each had two levels, with one being preferable.

A discrete choice analysis was used to evaluate the relative importance each factor had on decision-making by surveying oculoplastic surgeons. Participants were randomly assigned 14 out of 40 hypothetical ptosis procedure scenarios, asking physicians to choose between completing a procedure in the PR or OR. For all scenarios, OR reimbursement was $550. Key physician characteristics were collected: urban vs rural location, surgery center ownership, age, years of experience, and number of ptosis surgeries performed. Analysis was conducted using an econometric model that assumes physicians decide whether to use the PR by evaluating a random utility function.

Results
68 oculoplastic surgeons completed the survey, yielding 882 observations. Age and years of experience were highly correlated (.97) and only years of experience was used in the analysis.

Increasing PR reimbursement increased probability of choosing PR, with diminishing effect as reimbursement rose above $1100. Risk factors demonstrated expected directional effects: serious comorbidities, sedation requirements, and logistical issues each reduced probability of PR use for a given reimbursement. Rural offices dramatically increased probability of choosing PR. Number of surgeries performed slightly increased probability of PR choice for every 100 prior surgeries. Ownership and years of experience were not significant.

Conclusion
The model revealed reimbursement is the most important factor, especially at $1100 or more, followed by practice location, sedation, number of surgeries, logistical issues and comorbidities. The results suggest if all risk factors are low, doubling reimbursement increases the likelihood of using the PR by 35%. If all risk factors are high, the likelihood increases by 17%. This study shed light on the factors surgeons use to evaluate ptosis surgery location choice. The insight gained through this analysis will hopefully inform policy decisions and lead to a more efficient and thoughtful use of resources.

The Impacts of Reimbursement Rates on Ptosis Procedure Location Choice: A Discrete Choice Analysis

Background
The prevalence of diabetes and hypertension is disproportionately elevated in the Arab American population. Dearborn, the largest Arab American population in the United States, suffers specifically from these health inequities. The prevalence of diabetes in Dearborn is estimated to be greater than 18%, in a study conducted 20 years ago, with limited data suggesting more up-to-date figures. Hypertension, likewise, is also disproportionately elevated with over one-third of the population afflicted. These levels have called for urgent intervention by local and state health agencies, with reported glycemic goals being achieved in less than one-third of the population. These chronic, systemic diseases have many micro and macrovascular health complications; many of which manifest in the eye with resulting in irreversible vision loss. Hypertensive and diabetic retinopathy are among the most common ophthalmologic diseases and commonly result in painful vision loss, which alters the patient’s independence and self-confidence. These complications are financially burdensome with these patients having much needing consistent injections and intraocular surgery. By decreasing the health disparities found in this population, we can grant patients a better future in which we help save their vision.

These health disparities can be attributed to many things: language barriers, decreased access to medication, and decreased health literacy among other causes. One way to combat such inequity is with the Dearborn Sees project. This is a project in collaboration with the Dearborn Health Department (DHD), as well as pending cooperation with the American Association of Ophthalmologists (AAO). The goal was to design a website that is coded and written in Arabic from the ground up, with the most common ophthalmologic diseases explained in simple Arabic text and video that the common Arab American could understand. The website will also feature the ability to search for your nearest ophthalmologist and use artificial intelligence to triage symptoms from a questionnaire to suggest the degree of urgency of disease. 

Methods
Coding and building a website in Arabic with a database of Dearborn-based ophthalmologists and using artificial intelligence to triage potential ophthalmologic emergencies.

Results
This website is still being built, with the confirmed cooperation of the DHD, and pending cooperation of the AAO. 

Conclusion
The prevalence of diabetes and hypertension is disproportionally elevated in the Dearborn community. The implementation of technology that allows for easier comprehension for non-native speakers allows for far-reaching implications for many ethnically diverse communities throughout the United States.

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

Next from 2023 AMA Research Challenge

Racial Differences in Pediatric Localized Diffuse and Anaplastic Astrocytoma Survival