Clinical Topics in Global Family Medicine

Clinical Topics in Global Family Medicine

This theme consists of didactic sessions focusing on the exotic diseases that are indeed still encountered abroad, as well as the diagnosis and management of common and chronic diseases in resource-limited environments.

Workshop Topics

A Non-Gas-based Cryotherapy System for the Treatment of Cervical Intraepithelial Neoplasia (CIN): A Mixed-methods Approach for Initial Development and Testing

Globally, cervical cancer causes the death of 250,000 women every year in low- and middle-income countries (LMICs). Since cervical cancer can be prevented by treating precursor human papillomavirus (HPV) infections, public health efforts have focused on screening. In order to be effective in reducing cervical cancer mortality, screening methods must be coupled with effective treatment. Cryotherapy—which causes necrosis (cell death) of the affected area through freezing—is the most widely used treatment in LMICs. This method, however, involves the use of heavy gas tanks that need to be replenished continually and are difficult to transport. This session will outline the development of a novel, non-gas-based cryotherapy device specifically created to overcome the challenges in resource-poor settings.

A Revolutionary Integrative Approach to the Management of Chronic Pain and Depression

“Chronic pain” and “depression” are not actionable diagnoses. They are symptoms of a neuroinflammatory disease of multiple and compounding etiologies known as central sensitization syndrome (CSS). CSS is a new concept that redefines chronic pain as an immunologically-mediated neuroinflammatory disease that is only one manifestation of the neuroinflammatory process. Recently, novel research has identified other triggers involved in the pathophysiology of chronic pain and depression that are overlooked in the current treatments. This new understanding has led to the creation of a new map of neuroinflammation and a new treatment strategy. We will introduce a new, revolutionary approach for these conditions, including innovative pharmacologic treatments, nutritional therapies, mind-body techniques, and physical medicine modalities.

Appropriate Technology For Global Health

Health care is chronically in crisis—especially in low-resource settings. Resolution demands skilled leadership, with attention to health systems. One ethical principle for developing successful health systems is effective use of limited resources, including appropriate application of technology. Reliability, sustainability, and acceptability are principles used to determine whether the application of a technology is appropriate. Appropriate uses of technology in low-resource health systems include rapid diagnostic tests, mobile health information systems, ultrasound imaging, and adherence to the use of the World Health Organization’s Model List of Essential Medicines. Partnership with local partners and hosts is also essential. Their guidance greatly increases the likelihood that technology will be used appropriately. This presentation includes interactive use of role-play to enhance the learning experience.

Assessing Knowledge, Attitudes, and Barriers to Prenatal Care in Women of the Izabal Department in Guatemala

The University of Texas Southwestern medical and physician assistant students travel for short-term medical missions to rural areas in Guatemala with Refuge International (RI), a non-profit, American-based organization. As a quality improvement project, we assessed the knowledge, attitudes, and barriers to prenatal care among women in the Izabal Department region. Using a 29-item questionnaire designed through a literature review on the topic, we surveyed 23 women attending the RI clinics. Our survey revealed that almost 43% of women had one to three pregnancies, and 75% had at least one abortion or miscarriage. Seventy-four percent had sought prenatal care during their pregnancy, with less than 75% having attended four clinic visits or less. The main barriers to care reported were transportation and financial barriers. Our results will help direct future interventions focused on advancing prenatal care in the Izabal Department region through health awareness, resources, and training of health care workers.

Best Practices in Caring for Recently Arrived Arab and Muslim Women

Syrian, Iraqi, and Somali refugees are some of the most recent refugees being resettled in the U.S. at a time when the political and social environment in the U.S. is increasingly threatening to those who are perceived as Muslim or Arab. Much of the bias is fueled by the fact that most U.S. citizens have little knowledge of Arab and Muslim cultural values and traditions. The knowledge gap is particularly evident in the care of Arab and Muslim women. This session will provide participants with a quick review of best practices for care of these underserved and understudied women. Their care poses challenges for health providers unfamiliar with their health influences. Using a case-based format, topics to be covered for this female population include addressing family planning issues, screening for cancer, domestic violence, parenting, and mental health.

Biblical Beetles and a Severe Vesicating Dermatitis

Paederus beetles are found throughout the tropics, including parts of Asia, Africa, and South America, as well as the Middle East. Some have suggested the beetles may have been linked to the biblical third, fourth, and sixth plagues. These colorful, small, soft-bodied beetles are worth knowing about, not because of their bite or sting, but because inadvertently crushing even part of the beetle against the skin can cause significant skin irritation. Being able to identify the beetle, along with its preferred habitat and seasonal predilections, is important. Moreover, treatment recommendations, along with preventive consideration, can certainly lessen the impact this beetle may have on those traveling to areas where the beetle is endemic. The Paederus beetle an example of how basic medical planning and public health measures can minimize the effects of certain arthropod exposures.

Cervical Cancer Screening and Treatment in a Rural Hospital in Malawi: A Four-year Comprehensive Review

Eastern and Southern Africa, particularly Malawi, have the world’s highest incidence rates for cervical cancer, a condition that is preventable if found and treated early. In September 2012, Malamulo Adventist Hospital (MAH), a 212-bed rural hospital, initiated the only cervical cancer screening (CCS) program in Malawi, based on cytology testing, colposcopy, and loop electrosurgical excision procedure (LEEP). This study uses MAH’s clinical data to determine the number of women receiving these services over time; the proportion of women who had positive cytology tests (by age and by HIV status); and the proportion of women treated for either precancerous lesions or cancer. The study also reviews the successes and challenges that MAH faces in maintaining and expanding its CCS program, considering other approaches available in low-resources settings. Finally, this study discusses how Loma Linda University Family and Preventive Medicine residents contribute to this program through their curricular international rotation at MAH.

Chronic Mountain Sickness: A Brief Clinical Review and Genetics Update

High-altitude populations are located in two densities: 80 million people in Asia, and 35 million in the Andes mountain ranges. Chronic mountain sickness (CMS), or Monge’s disease, is a high-altitude pathological syndrome characterized by long-term exposure to a hypoxic environment. Disease burden is under reported, likely representing underestimation of disability-adjusted life years (DALYs) compared to controls. The diagnosis of CMS is considered clinical, with scoring systems designed to stratify severity. In the ideal setting, migration to lower elevation is curative for CMS patients. However, the majority of those affected are financially and personally restrained. In particular, both the Tibetan and Andean native populations lack access to care due to topographical and resource constraints. However, contrasting adaptations to high altitude among these populations suggest an evolutionary process, a hypothesis supported by recent genomic differences found in oxygen delivery physiology.

Clinical Challenges

Rutgers University has hosted the Mandela Washington Fellowship Program for Young African Leaders over the past several years. Every summer, 25 to 50 fellows of diverse professional and academic backgrounds participate in seminars related to civic engagement, civil society, community building, nonprofit management, political organizing, advocacy, fundraising, ethics, and volunteerism to build their leadership capacity. These fellows come from sub-Saharan countries of diverse religion, diet, culture, and health beliefs. When they feel ill, they often find the management of chronic disease and diagnosis of acute infection challenging in the U.S. health care system. Challenges include the battery of tests and long laboratory turn-around times, resulting in presumptive treatment with multiple antibiotics, and public health concerns among their dorm mates. The presenter of this session will propose a systematic approach to these global health concerns at hosting campuses and local hospitals in the U.S.

Clinical Management of Child and Adolescent Overweight and Obesity: A Normative Review

Childhood obesity was once thought to be a problem limited to high-income countries. However, epidemiological trends now show steady and substantial increases in childhood obesity across all income groups. To inform coming global World Health Organization guidelines on the issue, a review of all available clinical childhood obesity management guidelines from United Nation member states was conducted. Documents were analyzed across four domains: form, date, and country of publication; target audience; developmental methodology; and technical scope and content. Results of the study showed that the majority of documents originated from North American, European, or high-income countries. Guidelines generally reached consensus on preventive measures, but management guidelines varied moderately, and nutritional guidelines varied greatly. The most common recommendations supported use of multi-disciplinary teams (82%) and individual-based physical activity plans (72%). Despite 75% of the global overweight and obese child population living in low- and middle-income countries, this study demonstrates a conspicuous paucity of normative guidance from these countries, and highlights the need to further study obesity in these countries so that global guidelines may reflect their needs.

Clinical Update on Global Child Nutrition

Malnutrition is a leading cause and cofactor in child morbidity and mortality globally, and an often neglected area of clinical knowledge for health care practitioners and medical students. This workshop will review current demographics on the prevalence of undernutrition, micronutrient malnutrition, and over-nutrition (obesity), and discuss appropriate methods of nutritional surveillance and evidence-based management of acute malnutrition. Successful models for community-based interventions will also be covered, and consideration given to incorporating child nutrition work into global health programming. As nutrition and food security is complex and intertwined with politics, agriculture, and culture, we will also discuss a potential role in nutrition advocacy for global health practitioners.

Diabetes in Ghana and Around the World

During the presenter’s one-month global health elective at the Korle Bu Teaching Hospital Polyclinic in Accra, Ghana, an overwhelming majority of the patients were presenting with complications of diabetes. Since 2013, when it became the second most common cause for admission to the polyclinic ward, it has become a significant cause of morbidity and mortality, prompting the need for a diabetic specialty clinic at the polyclinic on Saturday mornings. Due to the sophisticated laboratory tests that are required to distinguish between type 1 diabetes and type 2 diabetes, separate estimates of diabetes prevalence for type 1 and type 2 do not exist at Korle Bu or even globally. However, in 2014, 422 million adults worldwide had diabetes. In Ghana, the prevalence has been estimated to be as high as 6%.

Ethics: Global or Local?

Ethics is defined as the discipline dealing with what is good and bad, and with moral duty and obligation. However, to what degree is medical ethics as a discipline universally accepted? Do different norms exist according to geography, culture, and/or degree of education? How do views of physician authority and the therapeutic relationship influence such? Case presentations from Central Asia and the Middle East will be discussed.

Fever, Nausea, and Unilateral Leg Weakness in a Border-crosser

A 34-year-old man of Mexican citizenship, with no known history, is brought into the emergency room by border patrol with a three-day complaint of left hip pain, difficulty walking, nausea, and diarrhea after four days of walking through the desert and drinking contaminated water. Evaluation was notable for temperature of 101.6°F, tachycardia to 107 bpm, lower abdominal tenderness, weakness on left hip flexion, open sores on feet, leukocytosis, borderline elevated creatinine kinase levels, and a computerized tomography (CT) scan of the abdomen showing a left iliopsoas abscess. We will discuss the common causes of iliopsoas abscesses, challenges to treatment in patients under border patrol custody, and other pathologies border-crossing patients present with.

Fighting the Diseases of Poverty

Poverty and health are intimately associated. Nations of poverty show the lowest life expectancy, greatest child mortality, and highest number of preventable deaths. Three interventions are especially effective. First, we must promote economic development. History demonstrates that as overall income increases, so does health status. Second, we must stand against military conflict. In embattled nations, more than 90 percent of deaths are from hunger and infectious diseases. Third, we must advocate those specific interventions that have proven most effective against the leading diseases of poverty, such as provision of safe drinking water and mosquito nets to prevent malaria, though these interventions may be inconsistent with the standard medical paradigm.

Finger-to-knee Distance as a Predictor of Lung Function in Pre-operative Spine Patients in Ethiopia

This study assesses the validity of using finger-to-knee (FTK) distance as a proxy for lung function in patients with kyphoscoliosis, a spinal disorder common among Ethiopian children and adolescents, which has the potential to impair lung function. Correlations between measured FTK distance and pulmonary function testing on 62 pre-operative spinal deformity patients were assessed. Significant correlations between the minimum FTK for each patient and both percent-predicted forced vital capacity (FVC) and percent-predicted forced expiratory volume in 1 second (FEV1) were found. Our data suggest that FTK is a reliable predictor of lung function in kyphoscoliotic patients, because it is representative of the severity of spinal deformity, which is an objective measure that can be used to prioritize patients who most urgently require corrective surgery. By validating this simple and effective way of predicting lung function, we provide a means to obtain valuable prognostic information in a low-resource setting.

Forsyth County Refugee Health Collaborative: Building an Algorithm to Enhance Access

This project represents a successful partnership we developed between our health department, our principal refugee resettlement agency, several area medical providers, and our state’s refugee health coordinator. Our initiative, the Forsyth County Refugee Health Collaborative, began as a resident advocacy project to enhance access and quality of care for refugees in our region, and grew into the current, well-established partnership. Our collaborative effort identified barriers and opportunities to connect refugees to medical homes, and created an algorithm that improved communication and organized interventions between the collaborative’s partners and medical practices, as well as the Department of Social Services and Medicaid. We are addressing social determinants of health on a broader scale, and have engaged speakers from legal channels and the local school system. Next steps include community outreach to enroll providers from the medical, mental, and dental disciplines, and coordination with key services in our community.

High-risk Low-resource Maternal Care

Surviving motherhood is a genuine concern. Maternal and newborn deaths make up the sixth- and seventh-leading causes of disability-adjusted life years (DALYs) lost in the world’s poorest nations. Post-partum hemorrhage (PPH), eclampsia-preeclampsia, abortion complications, and failure to progress are the leading maternal causes of death. Major modes of decreasing maternal morbidity and mortality are to reduce family size, and to provide quality obstetric care at time of delivery. Breastfeeding is the most natural, available contraceptive, with multiple additional benefits. Management of PPH requires immediate evaluation and intervention, particularly against atony. Basic newborn resuscitation should be universally available. Health care professionals must advocate for provision of these essential services to safeguard mothers and newborns.

How Can We Measure Success? Clinical Outcome Measures for Short-Term Medical Service Trips

Considering the volume of resources committed to short-term medical service trips, the current literature on clinical or patient-oriented outcomes of medical service trips (MSTs) is scarce. Shoulder to Shoulder Global provides a blended program of short- and long-term care through MSTs, and a permanent clinic in Santo Domingo, Ecuador. Using data collected over the last three years by the TimmyCare electronic health record, we share our initial experience with a health impact assessment based on preliminary measures of hypertension management. We will focus on descriptive statistics for a population of adult patients with hypertension, and discuss the challenges of measuring clinical quality in the setting of intermittent care.

How to Provide Holistic Preventative Care for a Resource-limited Patient Population in Apopka, FL

The Apopka Clinic is a student-run clinic that operates in partnership with the Farmworker Association of Florida. The University of Central Florida College of Medicine collaborates with the colleges of nursing, physical therapy, social work, University of Florida College of Pharmacy, and a chaplain to provide holistic medical care to a local underserved population. In addition to primary care, the clinic provides optometry, ophthalmology, gynecology, and pediatric services to a patient population that performs labor-intensive work, but has decreased access to health care. Due to the patients’ resource limitations, we have modified our approach to be highly economical in regard to prescriptions and referrals. Apopka also serves as a link to other resources to ensure the most comprehensive and continuous care. Education plays a large role in prevention of disease, and while our work to manage patients’ current conditions has the most immediate effect, our role in education and prevention has the most long-lasting impact.

Human Trafficking: An Overview

Human trafficking is a widespread problem, with estimates ranging from 14,000 to 50,000 individuals trafficked into the U.S. annually. This hidden population involves the commercial sex industry, agriculture, factories, hotel and restaurant businesses, domestic workers, marriage brokers, and some adoption firms. Health care professionals may be among the least likely to interact with victims during enslavement. About 30% of trafficked individuals will be exposed to the health care system at some point during their captivity, yet they are seldom recognized as victims. Lack of awareness due to sub-optimal educational opportunities plays a key role in why clinicians are not equipped to screen, identify, or care for victims of trafficking.

Hypertension Medication Adherence Survey at Rural Nicaraguan Outreach Clinics

Hypertension is one of the most prevalent diseases worldwide, and especially in the Americas, where it affects approximately 20 to 40% of the population. In order to gain insight into how previously diagnosed hypertensive patients in rural Nicaragua acquire and take their medications, a survey was performed in mobile outreach clinics outside of Sébaco, Nicaragua, during a five-day period in March 2017. The survey included six questions, modified from similar adherence instruments used by the Health Resources and Services Administration to evaluate antiretroviral therapy in the President’s Emergency Plan for AIDS Relief (PEPFAR)-funded projects. Seventy surveys were collected from patients with diagnoses of hypertension. With better surveillance and knowledge of barriers to medication adherence, we can develop strategies and patient education strategies to improve therapeutic adherence.

Inaugural Helicobacter Pylori Rapid Testing at a Rural Primary Care Clinic in Mayaya, Haiti

Gastroesophageal reflux disease (GERD) and gastritis are the most common clinical diagnoses at the FONDYLSAHH primary care clinic in rural Mayaya, Haiti. However, the rates of Helicobacter pylori-associated peptic ulcer disease (PUD) remain unknown. This cross-sectional study aims to measure the prevalence of H. pylori-positive cases seen at our clinic during April 9 to 16, 2017. Eligible patients were screened, and suspected patients were ordered a rapid H. pylori test. SD Bioline H. pylori stool antigen tests were used (98.4% sensitivity and 100% specificity). Results showed 110 potential cases of GERD/gastritis/PUD. Twenty-five of these patients were tested for H. pylori, with seven found positive and 18 negative. This was a pilot project to introduce H. pylori rapid testing in rural Haiti and treat positive cases. Implementation of this protocol was feasible and affordable in this resource-limited region. Challenges to adaptation were cultural barriers, clinic staff miscommunication, and limited space.

Knowledge, Attitude, and WASH Practices in Relation to Schistosomiasis Prevention in Kamanga Village North Western Tanzania

Tanzania is one of the countries with heavy burden of schistosomiasis, affecting mainly school children, primarily because of their water contact behavior. Two hundred participants, including caretakers and school children, were enrolled in a cross-sectional study. Both quantitative and qualitative data from the study showed that the majority of participants had no access to improved water and sanitation facilities, and lacked understanding of the role of water, sanitation, and hygience (WASH). These varying attitudes and practices, along with limited access to praziquantel, can exacerbate the problem, creating a vicious cycle of continued schistosomiasis transmission.

Latent Tuberculosis Infection

Latent tuberculosis infection (LTBI) is relatively common among the U.S. population (4.2%). There is a significant difference of LTBI rates among various groups depending on their country of origin. The clinical evaluation and treatment of LTBI is not well understood by many clinicians. Patient history, physical exam, radiology studies, and other laboratory testing should guide the clinician’s evaluation and treatment of LTBI.

Manual Laboratory Techniques for Resource-poor Settings

Many “old-fashioned” laboratory methods are obsolete, no longer utilized because advanced, automated methodologies exist. These techniques may be manpower- and time-intensive, but less expensive. In situations with limited resources, one may utilize “old-fashioned” technologies for clinical data not otherwise available. Because of regulatory issues, such as Clinical Laboratory Improvement Amendments (CLIA), many old techniques are not taught, creating a loss of expertise for simple, inexpensive laboratory methods. Modern laboratory standards and regulations prohibit these techniques for profit, but they may be utilized by private, licensed physicians who can utilize simple techniques in situations with limited access to “high-tech” medicine. This workshop will re-introduce low-tech clinical methods, doable by providers and useful in situations lacking in technology, equipment, or funding. Methodologies include: unspun urinalysis, urine culture, plate cultures, stained bacterial smears, erythrocyte sedimentation rate test, hematocrit, hemocytometer, and others.

Maternal Health in Zambia

Africa is the most dangerous place in the world for a woman to give birth. The maternal mortality rate in Zambia is 17 times higher than in the U.S. The disparities between health care for pregnant women in the U.S. and that in resource-limited countries like Zambia are highlighted. Factors for this inequitable distribution of maternal health services are identified. Serious maternal morbidities covered include obstetric fistula, ruptured uterus, and stillbirths, as well as special obstetric conditions like twin pregnancy and breech presentation. Specific patient-case scenarios have been collected from the maternity ward at Zimba Mission Hospital over a ten-year period. Cost-effective interventions with consideration of the appropriate setting can have an impact by significantly reducing morbidity and mortality for maternity patients in the developing world.

Parasitology I: Malaria

Although global health involves more than exotic infections, infectious diseases remain common in much of the world. Malaria is arguably the most important infectious disease in the world, today and throughout history. Pathophysiology, clinical presentations, diagnosis, transmission, treatment, and prevention—for both locals and expatriates—will be covered.

Parasitology II: Gastrointestinal Parasites

Recognizing that memories of your parasitology course in medical school may be distant, this session is the second part of a concise overview of the field of parasitology. Focusing on important worms and germs that infest the gut, this session will dust off those neurons used to describe the clinical symptoms, transmission and prevention, and treatment of parasites of the digestive tract. These parasites are responsible for significant morbidity. Simplified and amply illustrated with plenty of graphic images that will spoil the appetite of even the most stoic, this presentation will enlighten you far more about parasites than you probably desired.

Parasitology III: Vector-borne Parasites

The Zika virus captured the news, but what of other insect-borne infections? We examine vector-borne parasites (leaving the bacteria and viruses for another time). The majority of these worms and germs infest the body outside of the digestive system, and tend to be more malignant than the gut-dwelling ones. Don’t worry if your memory of prior parasitology courses is rusty. Simplified and amply illustrated with plenty of graphic images this presentation will recharge your knowledge base, and leave you with a remarkably persistent creeping sensation.

Parkinson’s Disease in North America: Trends, Challenges, and the Role of Primary Care

Parkinson’s disease (PD) is the second most common progressive neurological disorder worldwide. We review global demographic trends in the next decades, and their impact on the incidence and prevalence of PD. We also assess environmental risk factors and the affects of poverty, and compare the current and projected cost of PD management globally. As primary care physicians are the first health care resources that PD patients utilize, we assess the challenges they will face in managing PD in the future and discuss a potential global PD crisis, as well as proposing factors that can alleviate the challenges facing the diagnoses and management of PD.

Partnership to Care for Yazidi IDPs in Kurdistan

Since early 2016, family medicine has played a key role in a unique partnership serving more than 40,000 internally displaced Yazidi people in a camp in the Kurdistan region of Iraq. Partnerships between governmental and non-governmental organizations (NGOs) have contributed to the initial success of the project. The use of open source electronic medical records or “Open EMR” for clinic records has been a unique feature. Planning for a gradual transition from relief to development is the current challenge for the two faith-based NGOs involved in the project. This transition will be aided by the fact that one NGO is focused on relief and the other NGO is focused on long-term development. As the clinic matures, it will hopefully become a training site and serve as a model for a new approach for primary care in that region, not only for internally displaced people and refugees, but also for the general population.

Personal Medical History Card for Patients

When patients seek episodic health care at migrant clinics, refugee camps, “pop-up” clinics, health fairs, and during travel, they need their medical records available. Time or means to request and analyze records may be unavailable, and information must be appropriately updated for future encounters. This session proposes a simplified, one-page patient medical history card, maintained by the patient, and produced at each health care encounter. After visits, the card will be amended with appropriate information, and returned. This is similar in concept to the pediatric caccination card medical record. The card is designed to be folded to playing-card size and kept in a protector sleeve to prevent wear. Patients should be educated to present this for update at every visit, and keep it with them at all times. Empowering patients to maintain their own health information may increase portability, timely access to information, decreased medical errors, and a backup system for medical records.

Prevalence of Major Depression in Women Residents of La Limonada, Guatemala, Seen by Medical Service Team as Defined by Positive PHQ-9

An estimated 322 million people suffer from depression, making it the number one leading cause of disability worldwide. Lower socioeconomic communities, such as La Limonada, Guatemala (the second largest urban slum in Latin America), are often disproportionately affected. In March 2016, a medical service team from the University of Texas Medical School at Houston partnered with local community members to provide primary care services to residents and screen for depression using the Patient Health Questionnaire (PHQ)-9. The team serviced four different locations within La Limonada, and saw 326 total patients, all female adults over the age of 18. After analysis, 113 women had a positive PHQ-9 screen, giving an overall depression rate in this population of 58%. Of those who screened positive, 32% screened positive for moderate depression, 36% for moderately severe depression and 31% screened positive for severe depression.

Protocol for Evaluation of Ceramic Water Filters in Rural Honduras

Lack of access to improved sources of water affects over one billion people worldwide, creating the potential for waterborne illness and death, especially in infants and young children. Stand-alone clay water filters can be used to eliminate coliform bacteria from drinking water. The nonprofit organization, Humanitarian Outreach Medical Brigade Relief Effort (HOMBRE), has provided filters at reduced cost to rural communities in Honduras. Estimates for the lifespan of these filters range from 1 to 3 years, and there is anecdotal evidence they may last much longer. If this is true, rural communities could save significant resources by decreasing the frequency of filter replacement. We developed a portable, easily-implementable, and affordable method to evaluate functionality of filters of varying age and promote long-term sustainability of water filtration projects.

Refugee Health Care–Displaced But Not Forgotten

Refugee health care has become a pressing global issue. Today’s world has more refugees seeking asylum than at any time since the end of World War II. Eighty-six percent of refugees are hosted in developing countries, severely straining existing systems of public health, medical care, schooling, water, sewage, waste disposal, roads, environment, and politics. Provision of refugee care includes four recognized phases: pre-emergency/mitigation phase, emergency phase, post-emergency/maintenance phase, and repatriation phase. Throughout these phases, refugee health leaders must attend to concern over security, place of settlement, mental stress, dependency, and host-guest relations. This presentation makes use of role play and case studies.

Role of Advance Practice Providers (APPs) in Efficient Health Care Delivery

Analysis of health care shows inefficiencies in distribution workflow to APPs, resulting in decreased health care delivery and increased health care costs. Some of the problems with the work allocation are due to physicians’ trepidation about giving APPs too much autonomy in treatment of patients; unclear role definition and expectations; and lack of understanding of the APP role. These errors in workplace flow create increased health care delivery disparities in underserved areas. This is a phenomenon that is present throughout healthcare for a variety of reasons. Through researching the relationship between physicians, APPs, and patients, we found that APPs would be better utilized by communicating clear role descriptions; having physicians establish a line of care early; increasing APP autonomy; improving physician-to-APP approval time; and paying APPs a percentage of relative value units (RVUs) generated. These are findings that should help decrease discrepancies in care in underserved communities.

Sustainable Neonatal Resuscitation Programs Amongst Medical and Nursing Students in Dar Es Salaam, Tanzania

Each year in Tanzania, approximately 39,000 newborns die before their first birthday. Thirty percent of those deaths are due to complications, such as birth asphyxia. The need for neonatal resuscitation is most urgent in low-resource settings, where the burden is greatest and the capacity to provide adequate neonatal resuscitation is lacking. To address this critical gap, medical and nursing students at Hubert Kairuki Memorial University created a student-led organization to teach the program, Helping Babies Breathe (HBB). HBB is a hands-on training program designed to prevent neonatal mortality from birth asphyxia in low-income countries. This student-led organization achieves sustainability by maintaining a pipeline of student master trainers across university cohorts. To date, the group has trained more than 800 students and health care workers, and helped develop a similar student-led group at the Catholic University of Health and Allied Sciences (CUHAS) in Tanzania.

The ABCs of FGC/M: What Clinicians Need to Know

Female genital cutting/mutilation (FGC/M) is a practice that involves partial or total removal of the external female genitalia, or other injury to the female genital organs, for non-therapeutic reasons. It is common in several regions worldwide, and more than 100 million women and girls are estimated to have had FGC/M. The practice has serious, life-threatening health risks for children and women, manifesting acutely or chronically. Negative obstetric outcomes have also been reported. U.S.-based physicians may encounter FGC/M in their immigrant and refugee populations, and should have a basic understanding of the practice, its clinical management, cultural ramifications, and communication strategies. In addition, practitioners should understand the legal and ethical implications surrounding deinfibulation and reinfibulation, and their own beliefs regarding these practices. This presentation will draw on a variety of published sources, expert experience, and opinion to present best practices in the management of girls and women with FGC/M. The presentation will provide some case-based examples to promote discussion and problem solving within the group.

The Chronic Disease Tsunami

The two most prevalent diseases in the world are diabetes and hypertension. Combined, they lead to more death and disability than any other single health problem. Eighty percent of this burden is borne by the poor in developing countries. The poorest are hard pressed to accommodate the cost of the medications, lab testing, and doctor visits required to control their diseases. This epidemic poses a three-prong challenge: medical, social, and economic. The medical challenge involves addressing chronic diseases in resource-poor environments. The social piece of the puzzle speaks to the origins of the chronic disease epidemic (i.e., calorie dense processed foods, alcohol, smoking, and lack of physical activity). The economic problem is one of treating a multi-trillion dollar epidemic in the midst of a cycle of poverty. This presentation will explore how the non-profit organization, Chronic Care International, is addressing the three facets of chronic disease.

The Correlation of Magical Thinking, Superstition, and Educational Level to Health Literacy and Risky Behavior in Honduras

The aim of this study was to compare the prevalence of health-related superstitions among Hondurans who reached high school, compared to those who did not. Secondary aims were to correlate risky behavior, trust in physicians, and religiosity with medical superstitions. Investigators hypothesized no difference between the prevalence of medical superstitions in educated Hondurans and in less educated Hondurans. The study’s results appeared to confirm the hypothesis, and showed no difference in superstitious beliefs based on education level, possibly indicating their pervasiveness even in the highly educated. These results may prove significant for Western-trained physicians practicing in Honduras to improve their cultural sensitivity. This knowledge has the potential to help physicians partner with patients, and improve approaches to health care in this patient population.

The Experience and Effect of the Hypertension Management Model in the Primary Care of North Lima and Callao

Hypertension is a major risk factor for non-communicable diseases like cardiovascular disease, which is the most common cause of death in Peru. The causes of an increase in risk factors for hypertension, as well as cardiovascular disease, are related to unhealthy lifestyle factors, such as physical inactivity and increase in salt consumption. The Korea International Cooperation Agency (KOICA), in collaboration with the Yonsei Global Health Center, have implemented and provided a hypertension management program in three health centers of north Lima and Callao. Counseling, health education, and self-help group activities for lifestyle modification were provided to participants during a six-month intervention program by the KOICA-Yonsei health promotion team. Significant differences in blood pressure, body mass index, metabolic parameters, and lifestyles were observed. The findings provide that the hypertension program may be effective in the primary care setting in urban areas of Peru.

The Medical Evaluation of Asylum Seekers

Each year, thousands of people who suffered torture and ill treatment at the hands of governments due to ethnic and religious persecution flee their countries of origin and seek asylum in the U.S. Clinicians can provide expert opinion and critical documentation of torture and ill treatment in asylum proceedings. Family physicians, in particular, can leverage the unique, interdisciplinary lens of family medicine to fully evaluate the complex biopsychosocial impacts of torture and ill treatment. Beyond the provision of clinical expertise, the experience of conducting asylum evaluations can be very meaningful, and can broaden the scope and impact of family physicians as patient, community, and human rights advocates. The presentation will describe important considerations in conducting a medical asylum evaluation, and review common physical and psychological results of torture and ill treatment.

Wilderness First Aid Training in Peru: A Model for Wilderness Medicine in Latin America

The Asociación De Guías de Montaña del Peru (AGMP) exists to ensure mountaineering safety, and provides international trainings that equip participants with outdoor rescue skills. Wilderness first aid is critical to outdoor safety, but until recently was not incorporated into the curriculum. In 2016, the AGMP formed a collaboration with University of Colorado Section of Wilderness and Environmental Medicine to develop a wilderness medicine curriculum. A group of wilderness medicine faculty created a wilderness first-aid course in Spanish, which has been incorporated into the AGMP’s trainings. It is the only course of this type that currently exists in South America, and participants come from countries across Latin America. This education model provides skills training in a resource-poor context, with a goal of capacity building so that local AGMP guides may lead the courses in the future. A qualitative survey assesses strengths, weaknesses, and opportunities for improvement.

Wuchereria Bancrofti Infection in a Nepali Refugee Nine Months After Immigration to the U.S.: A Case Study

Wuchereria bancrofti is a filarial helminth parasite that infects patients via mosquito bite, causing disease by obstructing host lymphatic vessels. The World Health Organization (WHO) estimates that 13% of Nepal's population are infected. At present, more than 24,000 Bhutanese refugees from Nepali refugee camps have been settled in the U.S. in the past three years. The slow growth and long lifespan of this parasite will create a delayed clinical presentation of disease in patients seen many months after their arrival in the U.S. The speaker will present a clinical case study highlighting problems with diagnosis and treatment for this ubiquitous parasite.

Zika Virus in the Neonate

The Zika virus is the new fear factor in pregnant women and their babies. Zika has made its way all over the world and most recently to the U.S. The Aedes mosquito is the proven vector involved in the transmission of Zika, Dengue, and Chikungunya viruses. Co-infection with two or more of these viruses has been well documented. Refined diagnostic techniques, such as reverse transmission polymerase chain reaction (RT-PCR) and serology often yield false negatives. According to the Centers for Disease Control and Prevention, RT-PCR has unknown reliability in detecting Zika across the different stages of pregnancy. The consequences of these challenges have been paramount. After the Zika epidemic that began in 2015, numerous births with documented microcephaly have occurred. It is therefore imperative to probe pregnant women who test positive for any of these three viruses for the presence of Zika. In the event RT-PCR or serology yields negative results for Zika and positive results for either Dengue or Chikungunya, alternative diagnostic tools, such as fetal head ultrasound, newborn hearing and ophthalmology assessments, laboratory testing, and routine follow up must be employed to rule out Zika in neonates.