United States

As the novel COVID-19 pandemic was on the rise, its impact on the healthcare system was devastating. Patients became more reluctant to present to the hospital and elective procedures were being postponed for patient safety. We wanted to assess the effects of the COVID-19 pandemic on the door-to-device time in our small community hospital in the heart of Trenton, New Jersey. We created a retrospective study that evaluated all STEMI cases that presented to our institute from January 2018 until the end of May 2021. Our primary outcome was the door-to-device time. Secondary outcomes were the length of hospital stay, ICU admission, length of ICU stay, cardiac arrest, and death during the hospitalization. We studied 114 patients that presented with STEMI to our emergency department, 77 of these patients presented pre-COVID-19, and 37 presented post-COVID-19 pandemic. Our median door-to-device for STEMI cases pre and post-COVID-19 pandemic were 70 minutes (IQR 84-57) and 70 minutes (IQR 88-59) respectively with no significant difference found (P-value 0.55, Mann Whitney Test). It is, however, interesting to note that the number of STEMI admissions significantly decreased during the post-pandemic era. There are limitations to our study, most noticeably the number of STEMI cases at our small community hospital which limits its generalizability. Moreover, we did not assess other comorbidities which might have confounded our outcomes and we were also unable to follow patients post-discharge to assess the long-term sequela of their STEMI admission. Therefore, more dedicated studies of this clinical conundrum are required to further assess and implement guidelines for the future.

AMA Research Challenge 2022

Comparison of STEMI Door-to-Device Time during the COVID-19 crisis in a New Jersey Inner City Community Hospital


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IWSSIP 2021

poster

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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Difference in Severity of Heart Failure in Rurual Versus Urban Patients at Time of Referral for Advanced Therapies

Effect on Recurrent Emergency Room Visits and Hospitalizations in Atrial Fibrillation Patients in a Dedicated Nurse Practitioner Led Atrial Fibrillation Clinic 


Association of Cutaneous Manifestations with Admission Duration Among Dengue
Fever Patients in Rural, Underserved Philippines

Association of Cutaneous Manifestations with Admission Duration Among Dengue Fever Patients in Rural, Underserved Philippines

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.

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

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.

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Comparison of STEMI Door-to-Device Time during the COVID-19 crisis in a New Jersey Inner City Community Hospital

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