|CONFERENCE ABSTRACTS AND REPORTS
|Year : 2018 | Volume
| Issue : 3 | Page : 310-337
The Third Annual Academic International Medicine World Congress (AIM 2018) “Translating Evidence into Global Innovation” in Brooklyn, New York, July 27–29, 2018: Event Highlights and Scientific Forum Abstracts
Bonnie Arquilla1, Christina Bloem1, Ricardo Izurieta2, Donald Jeanmonod3, Rebecca K Jeanmonod3, Sudip Nanda4, Pia Daniel5, Thomas J Papadimos6, Miguel Reina Ortiz3, Manish Garg7, Michael S Firstenberg8, Sagar C Galwankar9, Annelies L DeWulf10, Gregory L Peck11, Ziad C Sifri12, Stanislaw P Stawicki13
1 Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
2 College of Public Health, University of South Florida, Tampa, Florida, USA
3 Department of Emergency Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
4 Department of Medicine, Division of Cardiovascular Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
5 Department of Emergency Medicine, New York-Presbyterian Medical Center, New York, USA
6 Department of Anesthesiology, The University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
7 Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
8 Department of Surgery (Cardiothoracic), The Medical Center of Aurora, Aurora, Colorado, USA
9 Department of Emergency Medicine, University of Florida, Jacksonville, Florida, USA
10 Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
11 Department of Surgery, Rutgers – Robert Wood Johnson University Hospital, New Brunswick, USA
12 Department of Surgery, Rutgers News Jersey Medical School, Newark, New Jersey, USA
13 Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
|Date of Submission||01-Dec-2018|
|Date of Acceptance||09-Dec-2018|
|Date of Web Publication||24-Dec-2018|
Dr. Stanislaw P Stawicki
Department of Research and Innovation, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, Pennsylvania 18015
Source of Support: None, Conflict of Interest: None
The Academic International Medicine World Congress (the AIM World Congress) is the official annual meeting of the American College of Academic International Medicine, a United States organization dedicated specifically to connecting academic physicians from diverse areas of expertise toward the common goals of sustainable global medical outreach and multinational clinical research and education. The organization's main focus is to promote academic international medicine and to establish a platform for individuals, academic institutions, and a broad range of multisectoral organizations to converge and work collectively to create a foundation for efficient, effective, and sustainable resource sharing. World-renowned experts and speakers from the AIM community attended and participated in the Third Annual Congress (AIM 2018) held in Brooklyn, New York, from July 27 to July 29, 2018. In addition to an increase in the number of high-profile faculty members, medical students, and other trainees, as well as the doubling our attendance compared with the AIM Congress 2017, this year's Annual Meeting also incorporated the Cochrane Diagnostic Test Accuracy Review Course. The conference theme, “Translating Evidence into Global Innovation” showcased efforts of the academic international medical community to utilize and create objective data to achieve global impact. Finally, the Congress featured the Second Annual Scientific Forum as a platform for exchanging scientific knowledge among scholars. This report presents an overview of this major academic event, including the listing of podium and poster presentations from the 2018 Scientific Forum.
The following core competencies are addressed in this article: Practice-based learning and improvement, Systems-based practice, Interpersonal and communication skills, Professionalism.
Keywords: Academic International Medicine 2018, Academic International Medicine World Congress, American College of Academic International Medicine, scientific abstracts, scientific forum
|How to cite this article:|
Arquilla B, Bloem C, Izurieta R, Jeanmonod D, Jeanmonod RK, Nanda S, Daniel P, Papadimos TJ, Ortiz MR, Garg M, Firstenberg MS, Galwankar SC, DeWulf AL, Peck GL, Sifri ZC, Stawicki SP. The Third Annual Academic International Medicine World Congress (AIM 2018) “Translating Evidence into Global Innovation” in Brooklyn, New York, July 27–29, 2018: Event Highlights and Scientific Forum Abstracts. Int J Acad Med 2018;4:310-37
|How to cite this URL:|
Arquilla B, Bloem C, Izurieta R, Jeanmonod D, Jeanmonod RK, Nanda S, Daniel P, Papadimos TJ, Ortiz MR, Garg M, Firstenberg MS, Galwankar SC, DeWulf AL, Peck GL, Sifri ZC, Stawicki SP. The Third Annual Academic International Medicine World Congress (AIM 2018) “Translating Evidence into Global Innovation” in Brooklyn, New York, July 27–29, 2018: Event Highlights and Scientific Forum Abstracts. Int J Acad Med [serial online] 2018 [cited 2019 May 27];4:310-37. Available from: http://www.ijam-web.org/text.asp?2018/4/3/310/248333
| Introduction|| |
The Third Academic International Medicine World Congress (AIM 2018) titled Translating Evidence into Global Innovation (the AIM World Congress) was held at State University of New York (SUNY) Downstate in Brooklyn, New York, between July 27, and July 29, 2018. Conference faculty and attendees included physicians and global health experts from >25 academic medical institutions from around the world. This 3-day conference was organized jointly by the American College of Academic International Medicine (ACAIM, www.acaim.org), with the generous assistance from SUNY Downstate Medical Staff and President, Dr. Wayne J. Riley. The AIM encompasses both clinical and nonclinical activities that broadly constitute a combination of international medical outreach and global health. One of the hallmarks of ACAIM is its dedication to multidisciplinary pursuits as the membership is inclusive of all medical and surgical trainees and practitioners without regard to geographic location of collaborating International Medical Programs (IMPs).,
Prominent topics discussed during the AIM Congress included the need for greater incorporation of AIM into the existing fabric of academic medical institutions; the standardization of metrics and collaborative frameworks relevant to AIM; research approaches and mixed-methodologies; the prominent role of women leaders in AIM; global health development, implementation, and evaluation; international health and health care security; educational programs in international medicine; violence prevention; emergency management and medical crisis response; ethical considerations in international academic initiatives; and application of global health lessons at home (e.g., reverse innovation). In addition, pre-Congress activities featured the world-renowned Cochrane Diagnostic Test Accuracy Review Course. The participating faculty listing is available under “Congress Program and Map” tab at http://acaim.org/home/aim_2018. Additional details, including multiple photographs and other multimedia links from the Congress, can be found on Twitter at https://twitter.com/acaiminfo and Facebook at https://www.facebook.com/1acaim. Medical and surgical specialties represented included anesthesiology, cardiology, cardiothoracic surgery, emergency medicine, general surgery, geriatric medicine, infectious diseases, internal medicine, orthopedics, pediatrics, primary care, and traumatology/critical care. In addition, various allied health professionals were represented, including emergency care, public health, and social work professionals. The 3-day conference featured a combination of joint plenary sessions and multi-track specialty sessions, as outlined below.
| Day 1: Friday, July 27, 2018|| |
The meeting began on a strong note with the ACAIM Task Force on IMPs [Figure 1]. The Task Force, led by Dr. Manish Garg and Dr. Sona Malkani Garg, discussed the creation of milestones for ACAIM members; examination of a collaborative framework to guide faculty and trainee assessment; and the utilization of multidisciplinary consensus group to promote standardization of core metrics. A parallel, all-day research seminar took place on Friday, with Dr. Yemisi Takwoingi and Dr. Anne Rutjes presenting the Cochrane Diagnostic Test Accuracy Review Course [Figure 2]. In addition to continuing medical education credits, participants also received a formal course completion certificate. Following ACAIM administrative meetings, the group enjoyed team-building activities during a social hour event.
|Figure 1: (Left) American College of Academic International Medicine leaders participating in the American College of Academic International Medicine Task Force on International Medical Programs; (Right) Dr. Manish Garg presents during the American College of Academic International Medicine Task Force session|
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|Figure 2: The Cochrane Diagnostic Test Accuracy Review Course: (Left) Prof. Anne Rutjes giving a lecture on methodological taxonomy; (Right) Post-course photo of American College of Academic International Medicine leaders and Cochrane faculty, left-to-right: Prof. Bonnie Arquilla, Prof. Yemisi Takwoingi, Prof. Anne Rutjes, and Prof. Christina Bloem|
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| Day 2: Saturday, July 28, 2018|| |
The 2nd day of the conference started with a networking breakfast. The opening ceremony featured a presentation by Dr. Wayne J. Riley, the President of SUNY Downstate Medical Center in Brooklyn, New York. This was followed by the Keynote Address titled, Where There's No Evidence: The Difficulty of Defining and Implementing Best Practices in Global Health Response, given by Dr. Craig Spencer [Figure 3], Director of Global Health in Emergency Medicine, at New York-Presbyterian/Columbia University Medical Center. The Past Presidents' Lecture then followed, with an insightful and stimulating oration titled, Dear Dean…-An Evidence-Based Approach to Advocating for Global Health in Academic Medical Centers, masterfully crafted and presented by Dr. Diane L. Gorgas, Executive Director, of the Ohio State University Health Sciences Center for Global Health. This concluded the Saturday morning session.
|Figure 3: (Top left) Dr. Craig Spencer presenting the American College of Academic International Medicine Keynote Address; (Top right) Dr. Spencer and President Arquilla during post-Keynote Award Ceremony; (Bottom left) Prof. Gorgas presents the Past Presidents' Oration; (Bottom right) Prof. Lasker presents on Pros and Cons of Short-Term Global Health Missions|
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During the lunch break, it was carried out the first scientific poster session followed by scientific podium presentations. The afternoon session started with Prof. Judith Lasker giving an oration on the topic of Pros and Cons of Short-Term Global Health Missions [Figure 3]. The highly attended session titled Women in International Medicine, Chaired by Dr. Christina Bloem [Figure 4], ran in parallel with the Scientific Forum. Finally, the 2018 ACAIM Consensus Group Meeting took place in late afternoon, with the focus on International Health Security: New Perspectives and Challenges, Co-Chaired by Dr. Sona Malkani Garg, Dr. Manish Garg, and Dr. Stanislaw Stawicki. Activities of the day concluded with the Official Congress Reception Event.
|Figure 4: Faculty and attendees engaged in lively discussion during the session, Women in International Medicine|
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| Day 3: Sunday, July 29, 2018|| |
Day 3 of the Congress began with a networking breakfast event. An “open mic” panel titled International Medicine Challenges then followed. During the session, Dr. Papadimos, Dr. Stawicki, and Dr. Richard P. Sharpe discussed various opportunities that exist for securing medical supplies and sharing experiential practices related to navigating difficult logistical and organizational issues. An insightful and interactive session on Injury Prevention by Dr. Robert Gore then followed. The morning session then ended with an expert panel titled Emergency Management: Medical Crisis Response, Co-Chaired by Dr. Pia Daniel, Dr. Sukhi Atti, Dr. Benjamin Kaufman, and Dr. Dario Gonzalez [Figure 5].
|Figure 5: Faculty of the expert panel titled, Emergency Management: Medical Crisis Response. From left to right: Dr. Pia Daniel, Dr. Timothy Tan, Dr. Christopher Tedeschi, Dr. Dario Gonzalez, Dr. Benjamin Kaufman, and Dr. Sukhi Atti|
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A parallel morning session featured a very interesting session titled Residency Review: An Ethical Framework for Evaluating Participation in International Academic Programs, by Prof. Susan B. Torrey. This was followed by an expert panel titled Ethical Considerations in International Academic Initiatives: Principles, Best Practices, and Coping with Challenges, Co-Chaired by Dr. Samara Soghoian, Dr. Annelies DeWulf, Dr. Jennifer Towbin, Dr. Braden Hexom, and Dr. Carrie A. Horwitch [Figure 6].
|Figure 6: Panel discussants during the session, Ethical Considerations in International Academic Initiatives: Principles, Best Practices, and Coping with Challenges|
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During the lunch break, the remaining 15 scientific posters were presented as a part of the resident paper competition. This was followed by four additional expert panels, beginning with Challenges in Pediatric International Medicine, Chaired by Dr. Ramon Gist with special speaker Dr. Louisdon Pierre. A panel titled Vulnerable Populations in New Jersey: Global Health at Home then followed. This panel was given by Dr. Richard Marlink, Dr. Kitaw Demissie, Dr Sneha Jacob, and Dr. Wenhua Lu. Parallel afternoon sessions included Polypharmacy Challenges given by Dr. Sage Wiener, Dr. Rana Biary, and Dr. Joel Gernsheimer. The final didactic session of the Congress was given by Dr. Mark Silverberg and Dr. Thomas Papadimos and focused on Low Fidelity Simulation for Resource-Limited Regions.
The Awards Session and Closing Ceremony then followed. The 3rd day of the conference ended with the ACAIM elections and Committee meetings. Foundational planning for the AIM 2019 Congress and Scientific Forum was also begun. Of note the following individuals received the honor of being the inaugural recipients of the Fellowship in Academic International Medicine – Alphabetically: Dr. Harry L. Anderson III, Dr. Bonnie Arquilla, Dr. Michael S. Firstenberg, Dr. Sagar C. Galwankar, Dr. Manish Garg, Dr. Rebecca K. Jeanmonod, Dr. Thomas J. Papadimos, Dr. Richard P. Sharpe, and Dr. Stanislaw P. Stawicki [Figure 7]. Finally, the most meritorious scientific presentations of the 2018 Scientific Forum were as follows – Alphabetically: Dr. Sukhshant Atti and team (Most Unique Poster Award); Dr. Roshanak Benabbas and team (Best Podium Presentation); Dr. Joseph Corcoran and team (Most Unique Podium Presentation); Dr. Thomas R. Wojda, Dr. Naffie Ceesay and team (Best Poster Award) [Figure 8]. Photographs from various associated events are shown in [Figure 9].
|Figure 7: Inaugural class of Fellows in Academic International Medicine; Not shown: Dr. Harry L. Anderson III, Dr. Bonnie Arquilla, Dr. Rebecca K. Jeanmonod, Dr. Michael S. Firstenberg, Dr. Thomas J. Papadimos|
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|Figure 8: Faculty and presenters participating in the 2018 American College of Academic International Medicine Scientific Forum; (Left) Scientific Poster Session; (Right) Research Awards Ceremony|
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|Figure 9: A collage of miscellaneous photographs from the Academic International Medicine 2018 Congress|
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Building on the success of AIM 2017 in Clearwater Beach, Florida, the AIM 2018 Congress was the most attended ACAIM event to-date. In addition to the high-quality didactic program, the 2018 Scientific Forum featured the largest number of abstracts in the history of AIM annual meetings. Changes on the ACAIM leadership team included the Presidential transition from Dr. Bonnie Arquilla to Dr. Manish Garg [Figure 10], Dr. Christina Bloem's election to President-Elect, and finally the election of Annelies L. DeWulf to the Organization's Vice-President. Finally, it was announced that the next year's Congress (AIM 2019) will take place at the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.
|Figure 10: Presidential Transition: Dr. Manish Garg, the Third American College of Academic International Medicine President receiving the Presidential Gavel from Dr. Bonnie Arquilla, the Second American College of Academic International Medicine Presiden|
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Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Abstracts from the 2ND Annual Acaim Scientific Forum|| |
Abstract Number 1
Paragonimiasis in Southeast Asian Immigrants: A Regional Problem Going Global?
Sarah Eapen, Eric Espinal, Michael S. Firstenberg
Department of Surgery, Summa Health, Akron, Ohio, USA
Introduction: Paragonimiasis is a parasitic disease caused by ingestion of freshwater crab or crayfish infected with lung flukes of the genus Paragonimus. The infection is most commonly seen in immigrants from Southeast Asia, Africa, and Central and South America. The clinical presentation is nonspecific, characterized by fever, productive cough, hemoptysis, and unintentional weight loss. These symptoms mimic those of pneumonia, tuberculosis, and malignancy. The radiologic features overlap as well. An additional challenge to the clinical diagnosis is the limited availability of serologic testing. We present two cases of paragonimiasis in Southeast Asian immigrants diagnosed after failure of medical management necessitated surgical lung resection.
Case Summaries: A 21-year-old male immigrant from Myanmar presented with a 5-year history of intermittent hemoptysis. He reported consumption of freshwater crab and wild boar while in Myanmar. Chest computed tomography (CT) revealed multiple nodules and airspace consolidation in the right lower lobe. CT findings prompted antibiotic therapy for pneumonia. Due to failure of medical management, the patient required a thoracotomy and right lower lobectomy. Surgical pathology demonstrated chronic inflammation and necrotizing granulomas. Associated parasitic organisms were morphologically consistent with Paragonimus westermani. Pathology findings prompted treatment with praziquantel, which led to symptom resolution.
A 36-year-old male immigrant from Myanmar presented with a 3-week history of cough productive of rust-colored sputum. He reported eating freshwater crab and crayfish while in Myanmar. Chest CT revealed a 3.4 cm × 2.2 cm cavitary lesion of the right middle lobe with surrounding reticulonodular infiltrate. Due to persistent symptoms despite 2 weeks of broad-spectrum antibiotic therapy, the patient underwent thoracotomy and wedge resection of the right middle lobe. Surgical pathology revealed inflammation and parasitic eggs, consistent with P. westermani. His symptoms resolved following treatment with praziquantel.
Clinical Discussion: Paragonimiasis is a foodborne parasitic infection caused by ingestion of raw or undercooked crustaceans containing lung flukes of the genus Paragonimus. Paragonimiasis is considered endemic to Southeast Asia, Africa, and Central and South America. It is extremely rare in the United States, with only 35 cases reported from 1910 to 2009. Paragonimiasis manifests with fever, chronic cough productive of rust-colored sputum, and hemoptysis. The definitive diagnosis of paragonimiasis is made by finding brown, ovoid eggs in sputum, bronchoalveolar lavage, or stool samples. The enzyme-linked immunosorbent assay test, an immunoserologic test for Paragonimus-specific IgG antibody, is highly sensitive and specific in the diagnosis of paragonimiasis. The treatment of paragonimiasis consists of a 2–3-day course of weight-based praziquantel. The cure rate approaches 100% following treatment.
Key Points: With a nonspecific clinical presentation, paragonimiasis often poses a diagnostic dilemma. With increased immigration from endemic areas, it is imperative that paragonimiasis is considered and recognized early in this patient population. Immigrants reporting consumption of raw or undercooked crustaceans are at higher risk. Eosinophilia should raise suspicion for a parasitic process as well. Chest radiographs and CT imaging may reveal characteristic nodules, cavitary lesions, or migration tracks. If available, serologic testing should be performed given the high false negative rate of sputum, bronchoalveolar lavage, and stool sampling. Once the diagnosis is confirmed, treatment with praziquantel should be initiated. Patient education is essential to the prevention of paragonimiasis. Hand washing and avoiding consumption of raw or undercooked crustaceans may reduce the risk of future infection.
| Abstract Number 2|| |
Emergency Department Overcrowding in a Tertiary Hospital in Porto Alegre: Improvement Model for the Flow of Patients
Silvana Teixeira Dal Ponte, Giordanna Andriolli, José Pedro Prates, João Carlos Santana
Department of Emergency Medicine, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
Introduction: Patient overcrowding is a worldwide problem in hospital emergency departments (ED). To continue maintaining the quality of care, some model to maintain a flow of patients in and out should be followed.
Methods: This is a descriptive observational study. A model was developed to regularize the outpatient flow to the ED of a tertiary hospital in Porto Alegre, Brazil. An educational process was instituted for patients. In addition, we designed a plan for more efficient patient disposition and follow-up, both inpatient and outpatient.
Results: After implementing the current model, we were able to reduce the number of patients referred from the outpatient clinics to the ED. We were able to institute a better educational process, orienting patients in good general condition and in the green classification of Manchester to look for an emergency care unit. We were able to reduce the time and permanence of the patients in the ED, with the discharge plan of the ward.
Conclusions: Organizing a management model for patient flow helps reduce the number of patients in the hospital, maintaining the quality of their care.
| Abstract Number 3|| |
Medical Relief in Puerto Rico after Hurricane Maria
Shaz Gangji, Lauren Roth, Eric Cioe-Pena
Department of Emergency Medicine, Staten Island University Hospital-Northwell Health, New York, USA
Introduction: Hurricane Maria hit Puerto Rico during a time when it was most vulnerable. Despite the humanitarian and federal assistance from the continental United States, thousands of Puerto Ricans are still left without power and other basic needs nearly 7 months later. Between October and November 2017, at the request of the Governor of New York State, the New York State Department of Health, the Healthcare Association of New York State, and the Greater New York Hospital Association worked with medical facilities across the state to develop and deploy two teams from New York Hospitals to spend 2 weeks assisting with medical aid. Both teams were able to treat approximately 11,000 Puerto Ricans. Team 1 consisted of 78 healthcare professionals including physicians, advanced care providers, nurses, respiratory therapists, paramedics, and emergency medical technicians from Albany Medical Center, Callen-Lorde Community Health Center, Montefiore Medical Center, Mt. Sinai Hospital, New York Presbyterian, and Northwell Health. Before the arrival of Team 1, the Puerto Rican Department of Health worked with the Federal Government to evaluate all of Puerto Rico's hospitals and conduct a needs assessment of the community. Via an Emergency Management Assistance Compact Mission Order Authorization Request, Puerto Rico requested a team of medical professionals to support medical facilities and Federal Medical Stations in Puerto Rico. The assets of New York State Team 1 were distributed around the island accordingly. The mission was to augment Emergency Department capabilities and services and decompress the existing departments. More often than not, the team worked alongside various government agencies including the United States Public Health Service Commissioned Corps, National Disaster Medical System, the Department of Defense, and the United States Department of Veterans Affairs. Patients across the island were afflicted with similar ailments as patients seen in the continental United States. For example, the Northwell Health team treated several patients with pneumonia, urinary tract infections, and cellulitis. Despite the preparation for natural disaster relief and the familiarity of illnesses encountered, there were many challenges and obstacles which made it difficult to provide the medical aid many volunteers had in mind.
Results: In Manati, an independent medical center was set up in a sports arena to allow for long-term care. Additional beds were set up to serve as a fast track/urgent care. In Fajardo, Caguas, and Ponce, federal medical stations were set up near hospitals as secondary emergency departments. Some health care professionals also teamed up with Americares to provide assistance in the form of mobile clinics.
Conclusions: Overall, the New York State teams were able to help approximately 11,000 patients, proving the mission to be a success. However, many challenges were encountered that could be remedied for future deployments. Perhaps, the most difficult aspect of providing medical care in Puerto Rico was providing dispositions for patients, particularly those on home oxygen and insulin-dependent diabetics. Without access to power, many nursing home patients were sent to hospitals to receive the care they needed, adding more congestion to already full hospitals. Communication between the various agencies posed a challenge as well. During the time of deployment, only about 15% of the cell towers were working, causing most communication to occur via satellite phones. There were many agencies in Puerto Rico ready and willing to help, but often resources and workforce were underutilized mostly due to a lack of communication. It is also important to note the occasional political issues encountered with for-profit hospitals. Thankfully, there was little to no shortage of supplies or medications. The needs of the island were met as needed. Nongovernmental organizations worked hand in hand with federal agencies to adapt to the needs of the people. Although the readiness to help was high, resources could have been better utilized in remote areas.
| References|| |
- Rodríguez-Díaz CE. Maria in Puerto Rico: Natural disaster in a Colonial Archipelago. Am J Public Health 2018;108:30-2.
- Cuomo GA. Governor Cuomo Announces Deployment of Health Care Personnel to Aid in Puerto Rico Relief Efforts; Published 12 October, 2017. Available from: https://www.governor.ny.gov/news/governor-cuomo-announces-deployment-health-care-personnel-aid-puerto-rico-relief-efforts. [Last accessed on 2018 Dec 09].
| Abstract Number 4|| |
Low-Fidelity Simulation Solution for Training Emergency Medicine Residents in the Performance of a Perimortem Cesarean Section
Juliana Jaramillo, Miguel Martinez, Maurice Selby, Daisy Grueso
Department of Emergency Medicine, SUNY Downstate Medical Center-Kings County Hospital Center, Brooklyn, New York, USA
Introduction: Cardiopulmonary arrest during pregnancy is uncommon; however, knowing the proper management is critical for maternal resuscitation and potential fetal salvage. The effectiveness of chest compressions is limited due to physiologic changes that are present after the 20th week of gestation. This includes caval compression due to the gravid uterus and increased metabolic demands of the mother and fetus during this time. Perimortem cesarean section (PMCS) has been described as a procedure that has led to the successful maternal resuscitation in multiple case reports, with some literature showing neurologically intact survival of the fetus, and remains standard of care according to the American Heart Association. Due to the infrequency of cardiac arrest in third-trimester pregnancy and importance of knowing how to efficiently perform a PMCS, training models and simulators may be useful in ensuring providers tasked with performing this procedure being able and ready to do so. This article describes the construction of a low-fidelity model to train emergency medicine residents on the indications, contraindications, required equipment, and steps needed to perform the procedure quickly and efficiently.
Methods: Inspired by the PMCS model devised by Sampson et al. and another low-fidelity model documented by Tamika C. Auguste and featured on the training section of the American College of Obstetricians and Gynecologists website, the following materials were required to construct and thus simulate a gravid uterus containing a >20 weeks gestation: empty letter-size copy paper boxes (e.g., staples, Xerox,) without the lids, staples, 3-inch × 50-yard duct tape, scissors, a box cutter, a foam mattress pad, a clear shower curtain, 15-inch child's play ball (a standard-size basketball or dodgeball are suitable alternatives), punching balloons, 9-inch × 12-inch red felt sheets, bubble wrap sheets that can be cut into 9-inch × 12-inch rectangles, and a small doll or stuffed animal approximately 12–20 inch in length. Using the aforementioned items, an abdominal wall and uterus were constructed. The uterus featured a penetrable “amniotic sac” that served to alert residents that they have entered the endometrial cavity before actually delivering the fetus. Simulated skin was made using a mixture containing glycerin, gelatin, water, and Neutrogena Healthy Skin Enhancer™. Approximately eight simulators were constructed and used during a multidisciplinary Procedure Day focused on obstetrical emergencies. Daisy Grueso, DO, an obstetrician and gynecologist and fellow at the Institute for Medical Simulation and Advanced Learning, served as the lead instructor for emergency medicine residents partaking in the PMCS simulation. Additional procedure stations included stations dedicated to shoulder dystocia, postpartum hemorrhage recognition and control, and neonatal resuscitation. More than 60 residents participated in the laboratories and were instructed and closely supervised by faculty of the Emergency Medicine and Combined Emergency Medicine/Internal Medicine Residency Training programs at SUNY Downstate Medical Center.
Results: We were able to create an inexpensive, low-fidelity model to teach emergency medicine residents the procedure of a PMCS. This model was used to assess and train residents to recognize when the procedure is indicated and enable residents to become proficient enough to perform the PMCS optimally and within 4 min of maternal cardiac arrest, a period of time within which the rates of survival are improved for both the mother and fetus if the PMCS is performed successfully. While no formal pre- and post-workshop surveys were conducted, resident feedback concerning the low-fidelity PMCS model was very good overall with most residents reporting improved knowledge of the procedure in all aspects and especially regarding comfort level in actually performing the procedure.
Conclusions: Regarding PMCS and other resuscitative procedures, the American Heart Association (AHA) in their 2015 AHA Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care stated, “Systematic preparation and training are the keys to a successful response to such rare and complex events.” Our low-fidelity model is an inexpensive way to teach emergency medicine residents and other providers to prepare for a rare and potentially life-saving procedure in pregnancy, and we are proposing this as a viable solution for those wishing to simulate the PMCS procedure using mostly available resources and minimal financial investment.
| Abstract Number 5|| |
Systematic Literature Review: Thrombolytics for Acute Myocardial Infarctions in Resource-Limited Settings
Sara Zelman, Courtney Meyer, Hiren Patel1, Sue Lahey, Lisa Philpotts, Thomas Burke1
Department of Emergency Medicine, Albany Medical College, Albany, NY, 1Department of Emergency Medicine, Division of Global Health and Human Rights, Massachusetts General Hospital, Boston, MA, USA
Introduction: As the global burden of disease shifts from infectious diseases to noncommunicable diseases, there is growing urgency to provide treatment for time-sensitive illnesses, such as ST-elevation myocardial infarctions (STEMIs). The standard of care for STEMIs in developed countries is percutaneous coronary intervention (PCI); however, this is inaccessible in resource-limited settings. Before the discovery of PCI, streptokinase (STK) and other thrombolytic drugs were the first-line treatments for STEMIs. STK has been recognized as a cost-effective and safe treatment for STEMIs; however, in settings which lack access to PCI, it has not become the established second-line therapy. A systematic literature review was conducted to geographically map the use of STK for STEMIs in resource-limited settings.
Methods: Our literature review group searched the databases CINHAL, EMBASE, Ovid, PubMed, Web of Science, and WHO's Index Medicus. The search terms included “thrombolytics” AND “myocardial infarction” AND “resource limited” and was restricted to human studies and papers written in English. A considerable number of studies came from Latin America; however, these studies were not written in English and were excluded. The initial search yielded 3487 articles, which was reduced to 3196 papers after titles were screened. Three medical professionals then screened abstracts, from which 291 articles were selected for full-text review and 94 papers were chosen for final inclusion. These articles were then analyzed and mapped geographically.
Results: This systematic literature review revealed that STK has been used for the treatment of STEMIs in 33 resource-limited countries, with 18 of 94 studies taking place in India. Furthermore, 13 studies occurred in Pakistan, followed by Iran (6), Sri Lanka (5), Brazil (4), China (4), and South Africa (4).
Conclusions: Our systematic review revealed that STK has been used for the treatment of STEMIs in 33 resource-limited countries, with the highest utilization occurring in India. This demonstrates that even though STK has high utility for STEMI treatment in resource-limited settings, it still has not become the standard of care. Future research should investigate the barriers preventing the establishment of STK use as second-line treatment after PCI.
| Abstract Number 6|| |
Globalism in the Collegiate Microcosm
James S. Papadimos
Department of Anesthesiology, University of Toledo, College of Health and Human Services, Toledo, Ohio, USA
Introduction: Malaria, a mosquito-borne disease, is considered to be the most prominent killer of humanity. The prevalence rate of malaria in 2015 was estimated to be 212 million cases and 429,000 deaths. The most high-risk and susceptible region is Sub-Saharan Africa. According to the World Health Organization, in 2015, Sub-Saharan Africa accounted for 90% of the malaria cases and 92% of the malaria deaths worldwide. Malaria has several strains: Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, related sibling species of Plasmodium ovale, and Plasmodium knowlesi, with P. falciparum as the most common and harmful strain to humans, and is responsible for 90% of malaria deaths worldwide. To combat this disease, I created a student organization at The Ohio State University titled “Just Net No Malaria,” to raise money and awareness for malaria nets. Malaria nets are feasible, easily accessible, and last for several years. They also are large enough to fit over a couple of adults or several small children. They provide the protection needed at night to shield humans from bites by the nocturnal vector of transmission, mosquitos.
Methods: To create this organization, I had to complete a multitude of administrative requirements. I first had to create the organization name and mission. I then submitted a request to attend the founder/president meeting training sessions and continued to attend these, eventually adding a vice president, treasurer, and a core council (3 members). Thereafter, a constitution was created which detailed the rules, regulations, responsibilities, and various other components to maintain order and structure in the organization. The final part required advertising and recruiting members to join the organization. It took a full semester and a half to get this organization legitimate funding and status. There were 20 active members, including myself. After graduation, I passed this organization on to the sophomore class members, which now have given me indication that over 30 members are now active (as of 2018). The organization managed to raise over 3000 dollars, while nets cost about 3 dollars. This fund has since grown as the goal is to cover an entire village as well as hospitals in Sub-Saharan Africa. Each room in the hospital will have a net per bed, while every family in the village will have 1–2 nets, depending family size.
Conclusion: This organization was the first of its kind on the campus of The Ohio State University and has become very successful. The very specific mission of this organization gave it unique abilities to make a large-scale impact on many lives. The organization raised money, as well as awareness, for insecticide-treated malaria nets, purchased them, and delivered them to areas of Africa most devastated by malaria. Nets have proven to be the single most effective preventative measure for malaria, as well as the cheapest. Data have also reported findings of villages that received nets for every family eradicated malaria from the area as the mosquitos had no source of nutrition.
| Abstract Number 7|| |
The Role of Point of Care Ultrasound in an International Surgical Mission
R. Valenzuela, P. Johnston, L. Marah, V. Padmanaban, J. Valenzuela, Z. C. Sifri1
Department of Emergency Medicine, SUNY Stony Brook School of Medicine, Stony Brook, New York, 1Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
Introduction: Lack of access to life-saving surgery in lower- and middle-income countries (LMIC) has been gaining significant attention. The World Health Organization and the Lancet's Commission for Global Surgery increased burden of noncommunicable diseases and stressed the high morbidity and mortality incurred by lack of access to appropriate surgical care. International Surgical Health Initiative (ISHI), a nonprofit organization created to address the need for essential surgery in LMICs, has performed over 1500 surgeries in the developing world on three continents and seven countries. In 2018, ISHI surgical team returned to Kabala, Sierra Leone, joined by an emergency medicine (EM) physician. One of the goals of the EM team was to provide point-of-care ultrasound (POCUS) in the preoperative, intraoperative, and postoperative periods to provide much-needed information in a resource-limited environment.
Methods: A retrospective descriptive analysis of use of POCUS in the pre-, intra-, and post-operative course of patients undergoing definitive intervention for essential surgical diseases. Drawing from the underserved community in Kabala, the local healthcare team recruited and prescreened patients before team arrival for elective herniorrhaphy or hydrocelectomy. Local practitioners are limited to little more than their physical examination skills and single X-ray machine for their diagnostic workup. Two portable ultrasound machines were provided by Fujifilm (M-Turbo model and the highly portable IViz model) to assist ISHI's volunteer efforts in Global Surgery.
Results: On the 1st day of the mission, 86 preoperative evaluations were performed. Cases which were unable to be clearly characterized as hydrocele or hernia were referred for evaluation by POCUS. Sixteen ultrasound evaluations were performed, revealing four cases with hydrocele complicated by inguinal hernia. The ultrasound was also used intraoperatively to evaluate for testicular blood flow during herniorrhaphy in three cases. POCUS was also used in the postoperative period in one case to confirm the absence of active blood flow in an incisional hematoma.
In addition to ultrasound use in the surgical setting, ultrasound imaging was also used to evaluate local patients in the ambulatory wards and maternity wards. In addition to evaluation of well pregnancies, intrauterine fetal demise of twins was also found in one case, and diagnosis of neonatal axillary cystic hygroma was also made.
In total, 60 ultrasound studies were performed. Of these, 13 groin ultrasounds were performed, 23 abdominal ultrasounds, 17 fetal ultrasounds, 2 FAST examinations, 1 cardiac examination, and 4 extremity ultrasounds were performed.
Conclusions: The use of POCUS has become an indispensable part of the practice of emergency medicine in high-income countries. The immediate feedback is extremely useful in short-term surgical missions in LMICs where decisions to provide essential surgeries have previously relied on physical examination or limited available radiographic imaging in the host country. The use of POCUS in LMICs is barely described in the international EM or Global Surgery literature. We believe that in these settings as portability of ultrasound units and battery longevity continues to improve, POCUS can provide much-needed information to Global Surgery initiatives where reliable and convenient medical imaging may not readily available. It also represents a great opportunity for clinical collaboration among specialties focused on global health.
| Abstract Number 8|| |
Corneal foreign body removal using low-fidelity simulation
Maria-Pamela Janairo, Mark Silverberg
Department of Emergency Medicine, State University of New York Downstate/Kings County Hospital Center, Brooklyn, New York, USA
Introduction: Ophthalmic trauma is a significant cause of preventable morbidity and is the most common cause of monocular blindness worldwide. Studies have shown that open globe or penetrating injuries account for approximately 12% of the injuries reported. In these cases, a patient is in need of emergent ophthalmologic consultation. However, nonpenetrating, corneal foreign bodies can be managed safely in the emergency department setting. A thorough history of present illness, basic ocular testing, as well as clinical suspicion, will aid in the diagnosis of a corneal foreign body. Improper technique to extract corneal foreign bodies can lead to perforation of the anterior chamber, corneal scarring, worsening of vision, and infection. The utilization and implementation of training for ocular emergencies using low-fidelity simulation will aid to gain experience and develop psychomotor skills to manage corneal foreign bodies. Trying to develop skills to remove corneal foreign bodies on actual patients is particularly dangerous, especially if the clinician has never attempted it before. The use of simulation has been shown to alleviate these concerns
Methods: We constructed a corneal foreign body removal simulator out of household items. First, a rubber “super ball” had a 1/8-inch deep cup drilled out of one side using a 1/2-inch drill bit. Next, a hole was drilled through the ball in an axis perpendicular to that cup, so 1/8-inch wide stock could be passed through the ball. The rubber ball was mounted in the middle of the stock. If threaded stock is available, two nuts can be utilized to secure the ball firmly in the middle of the stock. Finally, nondrying modeling clay was used to fill the cup, and a small piece of rust was embedded in the clay. The stock could be mounted in the slit lamp using simple tape, and foreign body removal could be practiced through the slit lamp with a 25G needle.
Results: This low-fidelity simulator provides a realistic model to remove corneal foreign bodies in a resource-limited setting. The simulator is easy to construct requiring only household items and a drill. The cost of such a simulator is <$5 and takes >10 min to construct.
Conclusions: Ophthalmologic corneal emergencies are often difficult to simulate in a limited-resource setting. This model can be used to educate learners to safely perform foreign body removal from the cornea in a controlled, safe environment. In addition to appropriate medical care, this low-fidelity simulator can ultimately aid in the prevention of irreversible blindness caused by corneal foreign bodies. It is also cost-effective, reusable, and constructed with common household materials.
| Abstract Number 9|| |
Mental Health Epidemiology of Traumatic Brain Injury Patients in Moshi, Tanzania
Elizabeth Ginalis, Sophie Galson, Brian Meier, Joao Ricardo Nickenig Vissoci1, Leonardo Pestillo de Oliveira1, Catherine Staton1
Rutgers Global Health Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, 1Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA
Introduction: Globally, traumatic brain injury (TBI) is the most common cause of injury-related morbidity and mortality, with a substantially greater impact in low- and middle-income countries (LMICs). TBI severity and clinical characteristics are influenced by a patient's preinjury mental health. Studies investigating pre-TBI psychological indicators have found that psychiatric illness is a risk factor for TBI. However, there is limited information on the relationship between psychological factors and resulting TBI clinical characteristics, particularly in LMICs. Therefore, we sought to describe the mental health, functionality, and sociodemographics of TBI patients in Moshi, Tanzania.
Methods: This study was composed of 214 patients who were part of a TBI patient registry and posthospitalization cohort study in Northern Tanzania. Patients enrolled in the study sought acute care for a TBI, were 18 years or older, and agreed to participate before discharge. These patients were evaluated using seven instruments to evaluate patients' depression (Patient Health Questionnaire-9), psychological distress (Kessler Psychological Distress Scale), alcohol use behavior (Alcohol Use Disorders Identification Test), quality of life (Short Form-8), functionality (Functional Assessment Measure), cognitive impairment (Montreal Cognitive Assessment), and TBI severity (Glasgow Coma Score). All instruments were administered to patients at bedside after hospitalization and served as a baseline for future follow-up evaluations.
Results: In this study population, the majority of TBI patients sustained a mild TBI (with a median Glasgow Coma Score of 15), had a formal education (n = 176; 82%), and were employed (n = 209; 98%), were married (n = 119; 56%), were males (n = 180; 84%) with a median age of 29 years. Several patients were identified with high hazardous alcohol use (n = 48; 22%) and cognitive impairment (n = 173; 81%). Despite high alcohol abuse and cognitive impairment, there was an unexpectedly low incidence of depression (n = 3; 1.4%) and psychological distress (n = 1; 0.5%) within this group.
Conclusions: Before injury, several mild TBI patients demonstrated harmful alcohol use and poor cognitive function without depression or psychological distress. Consequently, despite contrasting results from previous literature, there may not be a relationship between pre-injury depression and psychological distress with risk of mild TBI in the Tanzanian population. Alternatively, hazardous alcohol use and poor cognitive functioning may be risk factors for mild TBI. It is essential to further understand these comorbidities and their contribution to TBI risk to ultimately improve care of TBI patients in Tanzania.
| Abstract Number 10|| |
Post-Ebola Health Training in Gynecologic Oncology and Family Planning
Ann Marie Beddoe, Molly Lieber, Lise Rehwaldt,
Peter Dottino, Linus Chuang, John Martignetti,
Britt Lunde, Vishal Gupta, Milind Mahajan,
Brad Evans, Patricia McQuilkin1,
Michelle Niescierenko2, Angela Benson3,
Roseda Marshall3, John Mulbah3
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, 1University of Massachusetts Memorial Children's Medical Center, Worcester, 2Department of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA, 3Liberia College of Physicians and Surgeons, Monrovia, Liberia
Introduction: The West African Ebola Virus outbreak (EVO) highlighted the lack of health workforce capacity and the need to improve health education and infrastructure. The outbreak devastated Liberia and stretched its workforce capacity to the limits. When the outbreak abated, funds donated to a consortium of US institutions to improve workforce capacity during and in the aftermath of EVO were used to provide reproductive health training for Liberian Obstetrics and Gynecology residents in Liberia.
Methods: Seven faculty were mobilized from the fields of genetics, genomics, basic sciences, gynecologic oncology, radiation oncology, family planning, and clinical research. Each faculty member was tasked with designing a curriculum around their area of expertise, developing pre- and post-tests, and delivering the curriculum to residents in Liberia over 3 months.
Results: A total of eight residents participated. Pretesting demonstrated poor knowledge base in basic sciences, oncology, and family planning. Posttesting resulted on average in a 40% increase in knowledge after curriculum intervention. While residents were familiar with general genetics and genomics language, they lacked a clear understanding of its relevance in clinical oncology. Residents demonstrated a basic knowledge about cervical cancer but were able to explore the wider range of women's cancers, their risk factors, and management in resource-poor settings. Residents had the most knowledge about oral contraceptives but became familiar with the efficacy and acceptability of the newer long-acting reversible contraception methods.
Conclusions: The program highlighted the importance of linking basic sciences and patient/population-oriented research with clinic care. Although not directly relevant to another Ebola Virus-type outbreak, it is the hope that this program, by improving education and solidifying foundations of science, would stimulate participants' inquisitiveness to approach the next outbreak in a more comprehensive manner that will enhance human health and well-being. A major accomplishment of the program was that one of the trainees applied and was accepted into a pilot international gynecologic oncology fellowship program; the first physician in Liberia to have ever been given this opportunity.
| Abstract Number 11|| |
A Protocol for Medical Student-Led Hurricane Relief in Puerto Rico
Jani L. Swiatek, Joseph P. Corcoran, Christina G. Lopez, Manish Garg
Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
Introduction: Disaster relief is critical to hurricane victims and medical communities. In the fall of 2017, Puerto Rico was ravaged by two major hurricanes as per the Sariff-Simpson Hurricane Wind Scale that left nearly 100% of the island without power. Puerto Rico received much of its relief from the American Red Cross and the Federal Emergency Management Agency. These large organizations make a major impact with disaster relief efforts, but when needs outweigh available resources, other less established groups must intervene. The Temple Emergency Action Corps is a disaster service organization led by medical students. After review of the literature, we did not find previous examples of medical student-led hurricane relief to Puerto Rico. Our research describes a protocol for disaster response that is based on the model used to plan successful clinics in five towns in Puerto Rico that served over 600 patients in 5 days.
Methods: There are three major categories that must be addressed when planning a clinic in the wake of a disaster: current needs of the community, partnerships with community leaders, and funding for the clinics. Current community needs, including availability of supplies and medications, were assessed by establishing relationships with local doctors who provided real-time updates. Our community organizer provided input regarding the towns that would benefit most from free clinics, helped in choosing an optimal physical space to host the clinics each day, and recruited volunteers. In addition, funding was obtained from a nonprofit organization as well as through hospital and medical school donations that empathized with the cause. Overall, efforts were made to integrate the needs of the community with the available budget to maximize potential impact. Data from a prospective convenience sample of patients presenting to the clinics were obtained as a means to assess our success, report on current conditions, and publicize the continued need in Puerto Rico.
Results: With the help of the 19 medical students and physicians that came from the Lewis Katz School of Medicine and approximately 35 volunteers from the community, including doctors, allied health professionals, and invested community members, we provided patients with a variety of medical services including primary care, pediatrics, cardiology, gynecology (including pap smears), mammograms, dermatology, dental, psychiatry, and pharmacy. In addition, we provided basic hygiene products and distributed 500 bags (2500 pounds) of nonperishable food and cases of water, free of cost to patients. As measures of clinic success in terms of scope and needs addressed, we served over 600 patients in five high-need towns over a total of 30 working hours, for whom we prescribed and filled over 200 prescriptions, free of charge. Current conditions based on our sample population reflect continued need. Of those 600 patients, about 80% waited 90 days or more to have power restored (~24% still do not have power), 13% still do not feel safe in their homes 6 months after the hurricanes, and about 18% are coping with depression posthurricane. To publicize our findings, we have engaged with our institutional media services and have reached out to the Mayor's office in Philadelphia with a proposal to solicit more aid for Puerto Rico.
Conclusion: A medical student-led disaster relief effort to Puerto Rico is feasible and the model in which this was performed could help future medical students aspiring to lead similar disaster relief efforts. Assessing the current needs of the community in terms of supplies and medications needed, forming partnerships with community leaders, and securing funding for the clinics were the key categories that our group addressed while planning our clinics in the wake of two devastating hurricanes in Puerto Rico.
| Abstract Number 12|| |
Evaluating the Impact of an International Short-Term Medical Mission through Diabetic Glycemic Control
Hope Barone, Charlie Mach, Christopher Boni, Dan Sheps, Humberto Jimenez, Michael Tinglin
The Waves of Health, Rutherford, NJ, USA
Objective: To evaluate the impact of a primary care-based, international, short-term medical mission's (STMM) impact on diabetes disease burden as represented through reductions in hemoglobin A1C (HbA1c).
Methods: From November 2016 to May 2017, we tracked the HbA1c's of diabetic individuals in Dajabon, Dominican Republic, through care provided by Waves of Health. Participants were provided counseling, glucose monitoring equipment, a 6-month supply of antidiabetic medications, and received a “check-in” phone call at 3 months. HbA1cs were remeasured at 6-month follow-up.
Results: 75% (n = 76) of 101 participants presented for follow-up care. Mean and median HbA1c decreased from 8.71% (standard deviation [SD] 2.0) and 8.5% to 8.36% (SD 2.1) and 7.7%, respectively (P = 0.07). The percentage of individuals with HbA1c ≤7.5 increased by 10.4% at follow-up. The mean HbA1c decrease was 1.1%.
Conclusions: Although limited by sample size, our results suggest that medical STMMs may have a clinically meaningful impact in chronic disease management when utilizing a systematic combination of education, medical therapy, clearly documented medication instructions, and regular trip intervals.
| Abstract Number 13|| |
Global Contributors of Antibiotic Resistance
Aastha Chokshi, Ziad C. Sifri
Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
Introduction: Antibiotics have significantly reduced the burden of infectious diseases, which have previously been a major cause of mortality historically. However, now many pathogens have developed resistance to currently-prescribed antibiotics. In fact, it has been estimated that antimicrobial-resistant infections will lead to nearly 10 million deaths per year and a total gross domestic product loss of $100.2 trillion by 2050 if appropriate actions are not taken. Since infectious pathogens are constantly evolving and developing antibiotic resistance, it is essential to examine the key socioeconomic and political factors which contribute to the rise in the prevalence of antibiotic resistance in developing and developed nations. The purpose of this study was to conduct a qualitative literature review of the various factors contributing to the rise in antibiotic resistance globally.
Methods: PubMed was used to identify primary research, systematic reviews, and narrative reviews published before January 2017. Search terms included antibiotic resistance, antimicrobial resistance, superbugs, multidrug-resistant organisms, developing countries, developed countries. Publications from different countries were included to ensure generalizability. Publications were excluded if they did not mention factors causing resistance, focused on the molecular basis of resistance, or if they were case reports. Publicly available reports from national and international health agencies were used.
Results: Search results yielded 2281 publications for developing nations and 1227 publications for developed nations, of which 19 publications for developing nations and 13 publications for developed nations were included in the review. In developing nations, key contributors identified included (1) lack of surveillance of resistance development, (2) poor quality of available antibiotics, (3) clinical misuse, and (4) ease of availability [Figure 1]. In 2014, only 11.3% of countries had surveillance data on all nine antibiotic-resistant infections deemed to be emerging global threats. An increasing number of antibiotics available are often substandard or expired, which increases resistance rates by 2–6-fold. Clinically, antibiotics are improperly overprescribed in about 94% of cases across multiple nations. Finally, “self-medication” is a significant contributing factor, especially since antibiotics are easily available to the general population without a physician's prescription in about 81%–88% of cases. In industrialized countries, poor hospital-level regulation and excessive antibiotic use in food-producing animals play a major role in leading to antibiotic resistance [Figure 1]. Only 39.2% of US hospitals have implemented antibiotic stewardship programs, which are associated with reduced drug resistance. Nearly 7-9 million kg of medically relevant drugs were sold over the counter for use in food-producing animals every year since 2009. Finally, the lack of economic incentives for antibiotic research impedes the development of novel antibiotics, which has been continuously decreasing.
|Figure 1: Major Socioeconomic and political factors contributing to antibiotic resistance in developing (green) and developed (red) countries|
Click here to view
Conclusion: The results highlight that the increase in the prevalence of antibiotic resistance globally is due to multiple factors, which are distinct for developing and developed countries. To reduce antibiotic resistance, it is essential to improve the regulatory framework for antibiotic use globally as well as promote research on novel antibiotics. It is important to have a clear set of guidelines, set by international agencies such as the WHO, upon which the regulatory frameworks in individual nations can be based. In developing countries, the manufacturing process, quality, availability, and use of antibiotics need to be further controlled. In developed nations, hospital-based interventions and antibiotic use in food-producing animals need to be regulated in addition to promoting research. Finally, there also needs to be incentives for individual nations to adopt a stronger regulatory framework to implement these guidelines, in addition to providing aid for resource-poor countries.
| Abstract Number 14|| |
Lessons from Puerto Rico: Addressing the Health and Structural Challenges Faced by Postdisaster Communities
Joseph P. Corcoran, Jani L. Swiatek, Christina G. Lopez, Manish Garg
Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
Introduction: Following disasters, relief groups must choose how to best allocate supplies to optimize the recovery of affected communities. This requires deciding which communities have the greatest need and which supplies will have the greatest impact. Given the acute nature of disaster relief efforts and the unpredictability of natural disasters, prospective studies of on-site practices are scarce. Within limits, lessons may be drawn from retrospective analyses of response scenarios. The response to Hurricanes Irma and Maria striking Puerto Rico in September 2017 provides a unique lens to study response strategies due to the incomplete nature of the relief efforts. Acute efforts by Federal Emergency Management Agency tackled issues of hunger, water shortages and lack of shelter, but several key issues, such as mental health, were left unaddressed. In the months following the storm, Puerto Rico reported elevated rates of depression compared to the predisaster levels. Given the absence of a focused mental health response, we hypothesized that depression levels would still be elevated and sought to determine which factors might put survivors at increased risk. To evaluate the continued need for relief efforts and particularly the need for psychological aid, we report on the findings of the Temple Emergency Action Corps (TEAC), a medical student disaster relief organization that held mobile clinics across Puerto Rico in March of 2018, 6½ months (200 days) after Hurricane Irma struck.
Methods: Over a 5-day period in March 2018, a TEAC team comprised of four physicians and 15 medical students held mobile clinics in five towns across Puerto Rico (Arroyo, Maunabo, Patillas, Yabucoa, and Vieques). Clinics were advertised at least 1 month in advance via radio, internet, flyers, church groups, and word of mouth. In addition to TEAC's medical team, 35 Puerto Rican volunteers (physicians, students, and translators) joined the clinics each day. Validated screenings for depression (Patient Health Questionnaire [PHQ]9) and suicide risk (Ask Suicide-Screening Questions [ASQ]) were conducted on each patient who presented to the clinics. An IRB-exempt retrospective chart review was conducted.
Results: Medical charts were obtained from 587 patients. There were 645 visits with specialists, 143 vaccinations, and 41 mammograms. Sixty-seven percent of patients were female, 14% reported that they did not feel safe in their homes, and 8.2% did not have a PCP. Radio was the primary way that patients learned about the clinics (42.2%), followed by word of mouth (21.3%) and flyers (19.8%).
Thirty patients (5.4% of patients surveyed) reported that their water had not been restored, 142 patients (25.2%) did not have electricity, and 19 patients had neither. Yabucoa spent a longer time without power than any other town (P < 0.0001) and a longer time before water restoration than Arroyo, Patillas, and Vieques (P < 0.02). Electricity (P < 0.003) and water (P < 0.05) in Arroyo were restored significantly sooner than in Maunabo, Patillas, and Yabucoa.
19.3% of patients were depressed (PHQ9≥10) and 10.2% were at risk of suicide (ASQ ≥1). Depression was associated with suicide risk (χ2 = 38.8, df =1, P < 0.0001) and also with longer durations before water restoration (P = 0.0112). Patillas had a particularly elevated depression rate (29.6%) that was 1.7 times higher than any other town (χ2 = 13.98, df = 4, P = 0.0074).
Conclusion: These data indicate the continued need for medical aid in Puerto Rico. Moreover, they illustrate a need to customize disaster response strategies to individual communities and different populations of survivors. The discrepancies in PHQ9 scores between towns, as well as the differing amounts of time that communities spent without water and electricity, caution against using a one-size-fits-all disaster response plan. Furthermore, the elevated rates of depression and suicide risk across the five towns suggest the need for a more focused approach to postdisaster psychological trauma. The association between depression and the amount of time before water is restored to a community requires further study and may offer a viable strategy for combatting depression by prioritizing water restoration in postdisaster communities.
| Abstract Number 15|| |
Postdonation Survey to Assess Appropriateness of Medical Supply Donations to Freetown, Sierra Leone, following the Ebola Crisis
Alice Trye, Samba Jalloh1, Peter F. Johnston, Ziad C. Sifri
Department of Surgery, Rutgers, The State University of New Jersey, Newark, NJ, USA, 1College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
Introduction: The Recovery of Equipment for Capacity building OVERseas (RECOVER) initiative at Rutgers NJMS involves collection and donation of clean and unused medical supplies that would otherwise be discarded to those desperately in need of those supplies abroad. RECOVER has recently responded to the aftermath of the Ebola crisis and even more recent mudslide natural disaster in Freetown, Sierra Leone, in which the surgical capacity was greatly diminished. The goal of the study was to assess the match between the supplies donated and the local needs, using a postdonation survey.
Methods: In December 2016, we conducted a predonation survey inquiring which supplies available from RECOVER were in need by four hospitals in Freetown. The survey also asked about specific barriers to keeping such supplies in stock. After each hospital received a shipment of supplies, we administered an online Qualtrics follow-up survey consisting of 17 questions to assess the appropriateness of the donated supplies. The survey requested information regarding: (a) where specific supplies were used; (b) the most useful items; (c) the ability to sterilize items; and (d) whether the donation provided supplies that would otherwise need to be purchased.
Results: Recipient hospitals (n = 2) reported 75%–100% use of supplies. The most useful supplies were gowns, scalpels, gloves, and drapes; 50% of recipients reported the ability to sterilize donated goods. Supplies were used in operating rooms, emergencies rooms, and medical wards. Donated supplies provided both hospitals with supplies that would typically need to be bought or that were unavailable in the region. No adverse events were reported related to use of donated supplies.
Conclusions: At first glance, our donations appear usable and appropriate for the recipients. We hope to provide a framework for objectively evaluating the needs of hospitals in other low-income countries, using Freetown post-Ebola crisis as a pilot for assessment of medical supply donations. Moreover, we seek to examine the longitudinal impact of such framework on global health and surgery overseas. Future work will need to be done to further explore possible implications of our program including waste management and environmental considerations when donating and shipping disposable supplies to a developing country.
| Abstract Number 16|| |
Proposed Guidelines for Healthcare Equipment Donations: An Environmentally Conscious Approach
Asmi Panigrahi, Monica Maloney, Peter F. Johnston, Ziad C. Sifri
Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
Introduction: Unused and clean medical and surgical supplies, initially prepared for various procedures in the hospital setting, are regularly disposed of as solid waste. Salvaging and distributing these items have great implications in terms of the obvious humanitarian benefit as recipient institutions gain the ability to perform procedures, treat patients, and benefit the environment.
Methods: This presentation aims to identify some of the successes and failures of healthcare donation programs that have been implemented around the US. Investigators conducted a review of the current literature documenting the various supply recovery, donation, and reutilization programs that have been implemented in the US for the purpose of improving the medical system in low- and middle-income countries.
Results: Key topics that have been through literature review as improvements to both domestic and international guidelines include but are not limited to specialized predonation checklists for subspecialty donations, standardized postdonation evaluations and surveys, implementation of donation country medical waste legislation, standardization of medical waste streams, and incorporation of nonhazardous wastes into recycling methods as per municipal policies.
Conclusions: A host of important factors were identified through this comprehensive policy and program review. While the WHO Guidelines for Health Care Equipment Donations filled an important void in international health policy at the time of its inception, the growing number of supply-salvaging and international donation programs reveals a host of novel challenges amidst their many benefits in an increasingly globalized world.
| Abstract Number 17|| |
Developing Emergency Medicine: A Case Study of Free Open Access Medical Education and Emergency Medicine in Sri Lanka
R. Valenzuela, H. Cooray, S. DeSilva, S. Fernando, L. Fineberg, N. Lenora, M. Newcombe, G. O'Reilly, R. J. Salway, R. Seneviratne, N. Taylor, N. Wickramaratne, W. K. Mallon
Department of Emergency Medicine, Stony Brook University, Stony Brook, New York, USA
Introduction: Sri Lanka is a country of 21 million people, with a national socialized health system. Emergency care in Sri Lanka is delivered at large teaching hospitals free of charge. The 2004 Boxing Day Tsunami devastated Sri Lanka, raising awareness of the need for improved emergency care. The Australian Government (AusAID and the Government of Victoria), the Alfred Hospital, and Royal Children's Hospital in Melbourne assisted with development of emergency medicine (EM) in Sri Lanka. The Sri Lankan Government created the ministry post of Trauma Secretariat to aid in the development of a Trauma Registry. In 2013, the Sri Lankan Post Graduate Institute of Medicine created a formal training program in EM. The Sri Lankan Society of Critical Care and Emergency Medicine approved EM as a specialty in 2017. Developing Emergency Medicine (DEM) recognized these advances as an opportunity to introduce Sri Lanka to a new educational forum.
Methods: The principles of DEM are provision of educational program at locally appropriate cost, in an innovative manner, without financial conflicts of interest, to physicians in countries where EM is developing. DEM is a not-for-profit agency focused on providing a practical clinical approach to EM/critical care education aimed toward students and practitioners of EM, intensive/critical care medicine, and anesthesia. Education consists of conference, workshop-based education, and networking for ongoing international collaboration. Sessions and workshops are targeted to meet local requirements of the host nation and region. Lectures are delivered by expert volunteer international and local faculty who are young, dynamic educators from around the world. Faculty are users of Free Open Access Medical Education to collaborate with colleagues in low- and middle-income countries (LMICs) through DEM. Programs have involved disease processes, toxicology, and injury patterns found in the host nation and region and take into consideration the regional medical resources for care.
The conference has no pharmaceutical or device industry support and is solely funded by paid subscribers; their fees are used to subsidize attendance of local practitioners. DEM works with its contacts throughout Australia, Europe, and the Americas to identify potential partners. Before an event, members of leadership travel to the host country to meet with local champions and stakeholders, identify local needs and medical infrastructure, and locate local conference-hosting infrastructure. Most importantly, local participation is gauged to determine countries that would be most receptive of the conference's educational message.
Results: DEM Sri Lanka 2016 included local and international emergency practitioner delegates from 20 countries and faculty from 13 different countries. It was well received with 185 local Sri Lankan practitioners attending (almost the entire national community of EM focused practitioners). The DEM process allowed the local attendee registration charge for the conference and workshops to be heavily subsidized (10% of cost).
The conference included core sessions in Adult EM and Critical Care, Trauma, Pediatrics, and EM in Sri Lanka and the Region. Optional sessions included Toxicology and a Global EM Discussion Group. Local clinicians were involved as faculty and track leads for all sessions. There were eight allied workshops and two site visits to Sri Lankan health institutions. Social functions allied to the conference allowed a continuation of conversation and the development of ongoing relationships between clinicians from around the globe.
Conclusions: Conferences in LMICs, where EM is developing, can create significant sustainable impact and can help advance maturation of the specialty. The DEM conference in Sri Lanka in 2016 stands as a prime example and demonstration of this concept.
| Abstract Number 18|| |
Angioedema as the Presentation of Systemic Lupus Erythematosus
Jesus Granados, Diana Fleisher
Department of Emergency Medicine, SUNY Downstate Medical Center-Kings County Hospital, Brooklyn, New York, USA
Introduction: Angioedema is associated with medications, inflammatory diseases, and lymphoproliferative diseases. We describe new-onset angioedema as the presenting symptom of pediatric systemic lupus erythematosus (SLE).
Case Summary: Our patient was a 14-year-old African-American girl, born at 26 weeks gestation, with no other medical history. She presented to the emergency department (ED) with several days of diffuse abdominal discomfort, nausea, vomiting, and lower lip swelling.
The patient described sharp, constant abdominal pain radiating from left lower quadrant to right lower quadrant, associated with dysuria. She denied fevers, diarrhea, chills, hematuria, sexual activity, or recent travel. Reactive oxygen species was otherwise negative. She had neither personal history of allergy nor family history of angioedema. An abdominal X-ray showed a moderate amount of stool in the colon. She was discharged after improvement with ibuprofen and an enema.
Fourteen hours later, she returned with worsening symptoms and lower lip swelling. At that time, she denied pruritis, rash, tongue swelling, globus, or dyspnea. Subsequently, she received famotidine, dexamethasone, and diphenhydramine. Abdominal and pelvic computed tomographic (CT) scan showed diffuse intramural edema of the small bowel with ascites, consistent with angioedema. CT scan also noted bilateral hydronephrosis, hydroureter, and thickening of the bladder wall consistent with edema of the urinary tract system.
On blood tests, normal comprehensive metabolic panel (CMP) and albumin, normal comprehensive blood count (CBC), elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), low C3/C4, elevated C1-esterase immune complex, positive anti-ANA, positive anti-RNP, positive anti-SM, and elevated IgG immune complexes were observed.
The patient was admitted to pediatrics. After allergy/immunology, gastroenterology, rheumatology, and infectious investigations were complete, the final diagnosis was SLE with acquired angioedema. The patient's symptoms improved on steroids and she was discharged with rheumatology follow-up.
Clinical Discussion: Several disruptions of the complement cascade and kinin system are seen in inflammatory diseases, such as SLE, can cause acquired angioedema. Theoretically, such cases arise when antibodies to C1-esterase inhibitor bind to the complex and inhibit function, causing vasopermeability and angioedema; a likely explanation of this patient's presentation.
Key Points: In patients presenting with acquired angioedema without an iatrogenic or pharmacologic cause, SLE should be considered.
| Abstract Number 19|| |
Human Stampede Events: Aiming Toward Better Understanding and Primary Prevention
Alyssa Green, James Cipolla, Charles Bendas, Stanislaw P. Stawicki
Level I Regional Trauma Center, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
Introduction: Mass gatherings, including concerts, sports events, and religious festivals, are very common across the globe. Although generally safe, any occurrence involving large groups has the potential to result in a mass casualty incident (MCI). Human stampede events (HSEs) constitute a relatively common type of MCI, with involved participants exposed to significant risk of injury or death. Our objective was to perform a systematic review of HSE reported since the last definitive review by Hsieh et al. In addition to purely descriptive aspects of each HSE, we also sought to compile and categorize various risk factors and potential preventive strategies pertaining to events outlined herein.
Methods: We conducted a comprehensive English language literature search including Google™ Scholar and LexisNexis database for all records containing the terms “human stampede,” “injury,” and “mortality” during the period 2008–present. Significant events were defined as those involving >20 injuries or >10 mortalities. We recorded the location and time of occurrence, type of event, number of individuals involved, number of individuals injured or killed in the event, as well as the mechanism of HSE. Additional trend data were obtained from Google™ Trends.
Results: A total of 18 HSEs were identified during the study period. Overall 4277 injuries were recorded, with 1848 mortalities. Of those, 11 occurred in low/middle-income countries, while seven occurred in high-income countries. Approximately 73% of HSEs occurred at night, while about 27% occurred during daytime hours. Of note, 14/18 (78%) HSE occurred during a sport, religious, music/movie, or political event. Majority (14/18 or 78%) of HSE occurred in an outdoor location. In terms of HSE mechanism, six were unidirectional, four involved “turbulence,” and one featured a bottleneck, with the remainder being indeterminate. Google™ Trends search demonstrated that during the study period (2008–present), HSEs tend to peak during the late fall/early winter months.
Conclusions: Since the last definitive review, we identified 18 large-scale HSEs. Given the potential for significant injury and loss of life, more needs to be done to prevent and respond to these types of MCIs. Specific recommendations revolve around the incorporation of effective crowd control measures, careful preparation of the venue, and primary prevention of potential inciting events or factors. Crowd density and direction of flow should be strictly controlled, reducing the potential for any uncontrolled/turbulent flow within the crowd. New developments in crowd dynamics and mapping are being implemented to help better understand, and thus prevent, these deadly events.
A detailed review of postevent analyses demonstrated key factors associated with the occurrence of HS [Table 1].
| References|| |
- Hsieh YH, Ngai KM, Burkle FM, Hsu EB. Epidemiological characteristics of human stampedes. Disaster medicine and public health preparedness. 2009 Dec;3(4):217-23.
| Abstract Number 20|| |
Perceived Barriers to Implementation of Quality Improvement Initiatives in the Outpatient Setting: Implications for International Academic Programs
Thomas Wojda, Vikas Yellapu1, Piotr Zembrzuski, Sarah Baig, Rodrigo Duarte Chavez1
Department of Family Medicine, St. Luke's University Health Network, Phillipsburg, New Jersey, 1Department of Internal Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
Introduction: Although quality improvement (QI) is mainly used in hospital settings, ambulatory care clinics have also adopted QI initiatives to achieve certain goals. Examples include reducing appointment no-shows in children's mental health clinic; enhancing patient satisfaction; improving the quality of pap smears; bettering the follow-up of abnormal Pap smears; upgrading work processes; and expanding preventive care services. Nonetheless, more initiatives could be developed for this setting. Currently, little is known about barriers to implementation of QI projects in the outpatient setting. The purpose of this study is to describe the differences in perceptions of potential barriers to QI improvement projects in ambulatory care. The hypothesis is that there will be no difference between the categories of perceived barriers to implementation of QI projects.
Methods: Residency programs of a community-based academically affiliated health network were surveyed. Specialties evaluated included family medicine, internal medicine, surgery, orthopedics, emergency medicine, and obstetrics and gynecology. Participants were asked which hospital/specialty they currently practiced in, if they were an attending or resident, year of residency, and whether or not they were pursuing a fellowship. A five-point Likert scale was used to assess differences between resident and attending physician perceptions on potential barriers to quality improvement implementation. Questions regarding cost, involvement of individuals on the project team, ancillary staff participation, time commitment, perceived benefit, needs being met by the program, increased patient loads, drop in income levels, and lack of guidance were asked. Furthermore, level of agreement or disagreement of statements pertaining to barriers was assessed. Condensed questions are found in [Table 1]. Questions were drawn and modified from a previous study describing QI barriers in Scottish primary care practices. The survey was created, sent by e-mail, as well as delivered in person. Answers were stored using REDCap™ (Nashville, Tennessee) electronic data capture system. Analysis was performed using SPSS (Chicago, Illinois, USA). The sample size was calculated using RaoSoft™ (Seattle, Washington, USA) with 50 respondents needed to see a difference with alpha <0.05. Chi-square analysis was performed. Variables were examined as either those who were pursuing a fellowship vs. not pursuing a fellowship, surgical (general surgery, orthopedics, obstetrics) versus nonsurgical (family medicine, internal medicine, emergency medicine), and experience (postgraduate year [PGY]-I and II vs. PGY-III and up). Likert scale answers were grouped together as either agree and strongly agree (4 and 5) or unsure, disagree, and strongly disagree (3, 2, and 1).
Results: 72 surveys were collected. Campus and specialty are reported in [Figure 1]. 60 residents and 12 attending physicians responded. Frequency of year of residency is as follows: PGY-I 18.1%; PGY-II 29.2%; PGY-II 23.6%; PGY-IV 1.4%; and PGY-V 4.2%. Of 60 residents, 35 residents planned on or were going into fellowship versus 25/60 who were not or did not respond (58% vs. 42%). Number of responses and corresponding specialty are found in [Figure 1]. Results are displayed in [Table 1],[Table 2],[Table 3],[Table [Table 4].
|Table 1: Agreement or disagreement with the statements regarding quality improvement implementation|
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|Table 2: Difference in overall knowledge regarding quality improvement implementation in an outpatient setting|
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|Table 3: Provider perception of potential barriers to optimizing quality improvement project implementation and completion in an outpatient clinical setting|
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|Table 4: Description of variables determined to be significant based on Chi-square analysis|
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Conclusions: This study identified certain perceptions of barriers that may prevent optimization of quality improvement initiates. Specific barriers may include lack of knowledge for young trainees. In addition, persons looking to specialize may need more buy-in from ancillary staff and more education as to the relevance of QI in the clinical setting. Having early trainees actively participate in study design may be beneficial as well. These results may have wide-ranging implications for providing care in the developing world. By pinpointing barriers and targeting areas for improvement, ambulatory practices may be better empowered to deliver better more cost-effective care.
| Abstract Number 21|| |
Development and Implementation of a First Responder Program in Rural Haiti: The Involved Citizen Project
Annelies De Wulf, Adam R. Aluisio1, B. L. Hecht2, Christina Bloem3
Department of Section of Emergency Medicine, Division of International Emergency Medicine, Louisiana State University Health Sciences Center, New Orleans, 1Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, 2School of Public Health, SUNY Downstate Medical Center, Brooklyn, 3Department of Emergency Medicine, Division of International Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, USA
Background: The Northeast is a region in Haiti which lacks comprehensive prehospital emergency medical services. Most patients requiring medical care are transported via motorcycle taxis or on foot. Patients rarely receive prehospital care which, coupled with difficult road conditions, impedes time to medical treatment, contributing to morbidity and mortality. Utilizing a geographically oriented train-the-trainers model, this program aims to strengthen regional prehospital, acute care. Community leaders were trained in first aid skills and instruction and then trained other community members the first aid curriculum, with recruitment targeting local drivers with the aim of creating a cohort of emergency first responders in the region.
Methods: A geographically representative cohort of leaders to serve as trainers within the region was identified. These leaders were trained to teach a locally oriented first aid curriculum that emphasizes use of readily available materials in the provision of care and was developed in concert with Haitian partners.
Results: Thirty-five individuals were recruited, of which 51.4% achieved criteria to become independent trainers. Within 6 months of the initial training course, 44.8% of trainers reached reported using the skills they had been taught. The trainers taught 271 community members first aid skills within the study period. Of these, 33.1% of participants reached in follow-up surveys reported providing first aid in their communities and 19.8% had transported persons in need of emergency care to a healthcare facility since completion of the course.
Conclusions: This train-the-trainer model is an effective method for strengthening the capacity of communities to care for medical emergencies in the Northeast region of Haiti. This program will serve as an integral bridge to a future formal emergency medical services (EMS) system in the region and may be applicable to similar resource-limited settings.
| Abstract Number 22|| |
Medical Demographics in Sub-Saharan Africa: Measuring Temporal Trends in Emergency Department Visits among Elderly Patients
Vikas Yellapu1,2, Thomas Wojda1,3, Ileana J. Perez-Figueroa1,4, Alaa-Eldin A. Mira5, Chinenye Nwachuku2, Stanislaw P. Stawicki1,6
Departments of 1Research and Innovation, 2Orthopaedics, 3Family Medicine, 4Community and Preventative Health, 5Geriatrics, and 6Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
Introduction: As life expectancy increases around the world, unique challenges emerge in geographic regions unaccustomed to high volumes of progressively complex elderly patients with high comorbid burdens. One example of increasing life expectancy among low- and middle-income regions (LMIRs) is Sub-Saharan Africa (SSA). The UN projects that by 2020, the life expectancy in SSA is likely to increase by 2.5–10.4 years compared to the year 2000. The aim of our study is to perform secondary analyses of published literature sources to determine whether reported demographic trends from emergency departments (EDs) across SSA reflect the increase in life expectancy over the last three decades.
Methods: We performed an exhaustive literature search, looking for sources describing demographic information pertaining to ED encounters in SSA between 1990 and 2018. Our search strategy employed PubMed, EMBASE, Bioline International, and Google™ Scholar. Queries utilized the following terms in varied combinations: “emergency,” “trauma,” “department,” “ward,” “unit,” “survey,” “demographics,” “evaluation,” “geriatric,” “elderly,” with geographic qualifiers such as “Sub-Saharan Africa” and countries specific to this larger geographic region. Secondary searchers involved additional publications identified during the review of primary sources. After screening >1450 candidate studies, we arrived at a list of 36 publications with reporting of demographic data sufficient for inclusion. Descriptive statistical methods were used to present temporal trends in the context of primary study outcome – the proportion of patients defined as “elderly” as reported in each individual publication.
Results: We identified a total of 36 articles reporting on ED patient characteristics across various SSA countries, with source data ranging between 1990 and 2016. Geographic distribution of the studies in represented in [Figure 1]. Overall, we found an 8.9% increase in the proportion of patients reported as “elderly” by source publications during the study period (1990–1995 median of 3.6% versus 2013–2018 median of 12.4%). Temporal changes in this important demographic pattern are presented in [Figure [Figure 2].
|Figure 1: This map represents the distribution of data with highlighted areas representing the countries the studies where from|
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|Figure 2: This plot shows the interquartile range and median stratified into 5-year ranges starting from 1990 to 2018 period. The y-axis represents the portion of elderly patients admitted to emergency rooms in Sub-Saharan Africa|
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Conclusion: Our study provides support for the observation that demographics of aging population in SSA are mirrored across EDs in this fast-developing region. Our findings have several important implications for different domains of local health-care systems. Both providers and health-care facilities must be ready to treat increasingly complex patients with greater number of comorbid conditions and advanced pharmacological regimens. Targeted geriatric education should be offered to providers in SSA to help prepare them for this important demographic transition. Finally, emphasis should be placed on developing robust care of geriatric specialists to help optimize care for the fast-growing elderly population of SSA.
| Abstract Number 23|| |
Improving Broselow Tape Accuracy in Weight Estimation in the Emergency Department
Wajeeha Saeed, Akhila Mandadi, Upma Suneja, Saurabh Talathi, Omar Alharbi, Virginia Kaldas, Davami Rosario, Wallis Tavarez, Mark Leber, Muhammad Waseem
Department of Emergency Medicine, Lincoln Medical Center, Bronx, NY, USA
Background: In children, medication dosages and equipment sizes are weight based, requiring an accurate weight estimation. This is particularly true in emergency situations. Due to a rise in obesity prevalence, the accuracy of Broselow Tape (BT) has been questioned because of concern for under-estimation. We believe adding obesity variables to this tape may improve its accuracy.
Objectives: To determine the accuracy of the BT in estimating patient weight and whether other variables relating to obesity can be used to improve its accuracy.
Methods: This cross-sectional study was conducted in a pediatric ambulatory clinic in an urban academic hospital. Children up to 8 years were included. Exclusion criteria included the following: acute illness or the presence of any condition potentially resulting in growth disturbance. The normal range for BT is between 45.9 cm or and 146.5 cm. We measured mid-thigh circumference (MTC) and attempted to relate it to actual patient weight. We performed a stepwise linear regression model that tested four anthropometric measurements, keeping the BT measurement in the regression; the latter is considered standard of care relating to actual weight. Thus, we used a two variables model that included BT measurement and the mid-thigh circumference.
Results: Data obtained from the records for 301 children were included. Among the children included, 151 were boys (50.2%) and 150 were girls (49.8%). The MTC had the highest correlation with actual weight r = 0.88 (P <.0001). The relationship between actual weight and BT weight as well as mid-thigh circumference was found to be linear, and the trend was significantly different than zero (t = 10.4 and 22.6, respectively; P <0.0001 for both). This linear model accounted for 83% of the variance of the actual weight (R-squared 0.83, P < 0.009). The R square for the BT was 0.55, which was only a fair estimate.
Conclusions: The mid-thigh circumference and the BT were the measurements that showed significant correlation with actual patient weight. In our dataset, this two variables model improved the prediction of actual body weight over the standard BT measurement.
| Abstract Number 24|| |
Is There Competency-based Educational Benefit from a Medical Brigade Experience?
Emily J. Papai
Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
Introduction: The Association of American Medical Colleges (AAMC) and American College of Surgeons (ACS) provide a list of competencies expected of intern physicians that include an understanding of medical ethics, social determinants of health, and disparities in healthcare delivery. Such competencies can be met through exploring international medicine, while, in medical school, however, many available international medicine opportunities for undergraduate medical students are short-term experiences with limited institutional support. Global Brigades is a nongovernmental organization (NGO) that provides infrastructure for U.S. students to travel and work safely in underserved countries by facilitating temporary health clinics and public health initiatives. There is a need to assess the benefit and limitations of medical brigade style experiences regarding professional competencies via standards provided by the AAMC and ACS.
Methods: A 15-question survey derived from AAMC Expectations for Graduating Medical Students and ACS List of Desirable Skills for Interns was provided to Thomas Jefferson University students before and after a medical brigade trip to Choluteca, Honduras, in May 2018 involving six faculty, one professional, and 17 students in partnership with Global Brigades. Respondents selected a score from 1 to 10 on a Likert scale from “not confident” to “the most confident” about their abilities assessed in each question.
Results: Twelve students completed the pre-experience survey and eight students (73%) completed the postexperience survey. These were matched and two-tailed Mann–Whitney U-testing with 95% confidence was conducted. Each question failed to reject the null except “knowledge of various approaches to the organization, financing, and delivery of health care” with a U value of 12, indicating a significant difference in student confidence after the medical brigade experience in this measure. Evaluation of student confidence overall revealed an average increase in confidence across all questions of 0.791.
Conclusions: There is a positive effect on self-evaluated student competencies from participation in medical brigade experiences, especially for understanding health care systems. However, students searching for improved skill attainment before graduation through diverse and meaningful experiences may be limited by amount of faculty involvement, institutional guidance, and high personal cost to participate. Moreover, the brief period in the country likely also limits the significance of the experience on students. Increased competency attainment could be facilitated by professional acknowledgment of faculty participation and curricular support. Further research with the national competencies as an evaluation tool is warranted: on larger sets of students to improve power of the study and to compare other international educational experiences to medical brigade experiences.
| Abstract Number 25|| |
Risky Sexual Behaviors Associated With Human Immunodeficiency Virus Transmission among Pregnant Ecuadoreans
Nicole K. Le, Miguel Reina-Ortiz, Isabel Hernandez, Carlos Rosas, Vinita Sharma, Santiago Teran, Eknath Naik, Hamisu M. Salihu, Enrique Teran, Ricardo Izurieta
Department of Global Health, College of Public Health, University of South Florida, Tampa, Florida, USA
Introduction: Human immunodeficiency virus (HIV) infections in Ecuador have significantly increased since the beginning of the 2000s, with adolescents experiencing the greatest increase in HIV incidence. While HIV testing is offered to all pregnant women in the province of Esmeraldas, they substantially lack the information needed to facilitate informed decision-making and planning to prevent and treat HIV infections. Our study aims to determine the prevalence of HIV in pregnant women as well as provide updated information regarding the risk factors for and status of the HIV epidemic within Esmeraldas.
Methods: We conducted a secondary analysis of data collected from a cross-sectional study among pregnant women for HIV in Esmeraldas in 2010. Questionnaires from the study reported information about demographics as well as knowledge, attitudes, and practices regarding high-risk sexual behavior. Descriptive statistics, bivariate analyses, stratified analyses, and multiple logistic regressions were done.
Results: A total of 318 pregnant women completed the questionnaires. We observed 0.5% HIV prevalence overall, with a 1.9% prevalence among adolescents. The average age of coitarche was 16 (2.48) years. On average, adolescents scored 68% on questions regarding HIV/AIDS transmission compared to 84% among adults. Adolescents were twice as likely to have multiple partners compared to adults (23.1% vs. 11.7%). 75.3% of adolescents and 70.5% of adults have never used condoms.
Conclusions: Adolescents were found to have less knowledge of methods of contraception and prevention of HIV transmission. More education regarding risky sexual behaviors is needed, especially among adolescents to reduce the risk of horizontal and vertical HIV transmission.
| Abstract Number 26|| |
Comparing Perceptions of International Orthopedic Volunteers and Their Local Hosts
David W. Wassef, Jordan T. Holler, April Pinner, Sravya Challa, Meng Xiong, Caixia Zhao, Sanjeev Sabharwal1
Rutgers New Jersey Medical School, Newark, New Jersey, 1University of California, San Francisco, California, USA
Introduction: Growing musculoskeletal trauma in lower and middle-income countries (LMICs) has caused increased strain health care networks worldwide and heightened the need for well-trained orthopedic professionals to properly manage growing patient populations. The demand for orthopedic volunteering overseas has increased in response and has become an important tool for preparing local physicians to deal with increasing caseload and complexity. Positive educational and clinical outcomes of volunteer efforts are often reported by volunteers, but there is fairly limited information in the literature regarding host perceptions of these same experiences. Our goal was to compare the perceptions of overseas orthopedic volunteers and their hosts in LMICs regarding the role of international volunteerism.
Methods: Surveys with similar multiple choice and open-ended questions were administered to 163 health volunteer overseas (HVO) orthopedic volunteers (response rate 45%) and 53 members of the host orthopedic staff (response rate 40%). Quantitative responses were analyzed for significance using Mantel–Haentzel Chi-square tests.
Results: Both groups agreed that volunteers typically had the skills necessary to benefit the local patient population (75% of volunteers, 71% of hosts, P = 0.747), and ultimately provided contributions that were beneficial to the LMIC practices (96% of volunteers, 100% of hosts, P = 0.385). When asked about volunteer motivations, hosts recognized that volunteers were largely motivated to improve orthopedic care (100% of volunteers, 95% of hosts, P = 0.079) and the skills of orthopedic staff at the host practice (100% of volunteers, 95% of hosts, P = 0.076).
Hosts felt that volunteers were strongly motivated by their need to enhance their own clinical skills (67% of hosts, 29% of volunteers, P < 0.001) and professional career (90% of hosts, 23% of volunteers, P < 0.001), and two ideas volunteers did not share. Volunteers were also less likely than hosts to cite cultural barriers as impediments to interpersonal interactions during the volunteer experience (19% of volunteers, 43% of hosts, P = 0.018).
Conclusions: Efforts must be made to further align the expectations and goals of volunteers and their hosts in LMICs. Certain measures such as predeparture orientations for volunteers and developing a more longitudinal and bidirectional experience may enhance the impact of orthopedic volunteerism in LMICs. Further studies are needed to see if these results are generalizable to a wider volunteer and host population.
| Abstract Number 27|| |
Improving Disaster Preparedness among Pediatric Chronic Kidney Disease Patients: A Pilot Project
Sukhshant Atti, James Bricker, Stephen Kohlhoff, James Salway, Ramon Gist, Eric Persaud, Patricia Roblin, Bonnie Arquilla
Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
Introduction: Disasters impact all segments of the population but affect different populations disproportionately. The United Nations Children's Fund indicates that “children typically represent 50%–60% of those affected by disaster.” Children with special health care needs (CSHCNs) have increased vulnerability to disasters and it is imperative that they, and their families, are educated on the importance of emergency preparedness to minimize morbidity and mortality. Healthcare workers who provide regular services for CSHCNs have a unique opportunity to engage in emergency preparedness education and planning. The Centers for Disease Control (CDC) state that ~10,000 children and adolescents in the USA live with end-stage renal disease who need regular dialysis and therefore are a population of CSHCNs. Organizations, including but not limited to, the Kidney Community Emergency Response Coalition, the American Academy of Nephrology, and the National Kidney Foundation recommend emergency planning for chronic kidney disease (CKD) patients. In addition, the American Academy of Pediatrics, the Federal Emergency Management Agency, the CDC, and the American College of Emergency Physicians recommend that families with CSHCNs complete a standardized Emergency Information Form and a family disaster plan, to improve personal preparedness. This study assessed the knowledge and preparedness of families with children with CKD, and those on daily medications, before and after a brief intervention, and provision of a starter emergency preparedness kit.
Methods: Patients included in this study were screened and selected via a convenience sample at routine pediatric clinic and dialysis visits. Inclusion criteria for pediatric patients at the nephrology clinic were those pediatric patients taking daily medications, or those with a glomerular filtration rate <40, or those patients on dialysis. Other inclusion criteria for both clinics were that children be from ages 0 to 24. A brief survey, which was adapted from the Family Preparedness Survey, was used to assess their baseline preparedness knowledge. Families were provided with a brief educational intervention with a pre-written script. Families were provided with an Emergency Information Form and a Family Disaster Plan form and asked to complete it by their 30-day follow-up. Dialysis patients were provided with an emergency preparedness booklet, designed by the Centers for Medicare and Medicaid Services for dialysis patients, to complete by their 30-day follow-up, in addition to the aforementioned forms. Follow-up was completed with patients at 30 days via telephone, or in person at a follow-up appointment, by re-administering the initial preparedness survey, along with additional questions to assess changes in baseline preparedness level.
Results: Quantitative data are pending and will be available at the time of the conference.
Qualitatively, responses have been positive from an overwhelming number of enrollees, who have been motivated to improve preparedness after learning about their special vulnerability.
Results will be analyzed using appropriate non-parametric variable testing and for statistical significance using a P < 0.05.
Conclusions: The intervention used in this study has preliminary evidence showing that a 10–15-min educational intervention and provision of an emergency starter kit help improve personal emergency preparedness in vulnerable patient populations. Nursing staff and pediatric nephrologists at the pediatric dialysis center and nephrology clinic demonstrated buy-in and further planned on reviewing patients' emergency plans with them on a monthly basis as a result of this intervention. Pediatric patients with special healthcare needs are at far greater risk in a disaster due to their need to access medical care daily, requiring improved emergency preparedness.
| References|| |
- UNICEF. Towards a Learning Culture of Safety and Resilience: Technical Guidance for Integrating Disaster Risk Reduction in the School Curriculum. UNESCO; 2014.
- Centers for Disease Control and Prevention. Chronic Kidney Disease Surveillance Program (CKD); July, 2017; Available from: https://www.nccd.cdc.gov/ckd/AreYouAware.aspx?emailDate=July_2017. [Last accessed on 2018 Jun 13].
- Emergency preparedness for children with special health care needs. Committee on pediatric emergency medicine. American Academy of Pediatrics. Pediatrics 1999;104:e53.
- Blessman J, Skupski J, Jamil M, Jamil H, Bassett D, Wabeke R, et al. Barriers to at-home-preparedness in public health employees: Implications for disaster preparedness training. J Occup Environ Med 2007;49:318-26.
- Baker MD, Baker LR, Flagg LA. Preparing families of children with special health care needs for disasters: An education intervention. Soc Work Health Care 2012;51:417-29.
| Abstract Number 28|| |
Barriers Facing Emergency Trauma Care in Jamaica
Tayyaba Mohammad, Trevor Dixon1, Joanelle Bailey
Rutgers New Jersey Medical School, Newark NJ, 1Department of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
Introduction: Trauma care is a major barrier to healthcare in developing countries. The previous literature on Emergency Medical Services (EMS) trauma care in developing countries consists of a comparison of the trauma care between countries such as Australia, Canada, Greece, Germany, Iran, Mexico, the UK, and the US. The Pan-Asian Trauma Outcomes Study (PATOS) assessed the variability and deviation of EMS care across many of these countries. Another study assessing the barriers to emergency care in low- and middle-income countries in Africa, Asia, and Latin America found that the most frequently cited barriers to further development of prehospital care was inadequate funding and lack of legislation setting standards of care across countries. Expanding on previous literature, we asked doctors, nurses, firefighters, and emergency medical technicians (EMTs) to share their opinions on trauma care in various jurisdictions of Jamaica at the JAHJAH Foundation Trauma Conference this past year. Our objective was to assess the barriers to trauma care in Jamaica.
Methods: Thirty-six participants were asked to fill out a survey rating their level of proficiency in various emergency procedures, as well as to share their opinions on the quality of trauma care in Jamaica. Topics that were shed light upon included the emergency system, funding, perception of the community, and resource availability.
Results: The most common responses for barriers to trauma care were related to cost and supply shortage. Thirty out of the 36 people who completed the survey (83.3%) stated there was a lack of funding or lack of resources such as ambulances, automated external defibrillato (AED), and ultrasound machines. Three participants stated the need to increase the education and training of EMS personnel. Two participants recognized a barrier of long distances during patient transport to the hospital. One participant chose not to answer. There was plenty of overlap between the categories as well.
Conclusions: The barriers to emergency trauma care in developing countries have been studied in various Asian, European, African, and Latin American countries. There exists a discrepancy in trauma care between many developed and developing countries. Our survey showed that the most commonly stated barrier to care was lack of funding and lack of resources. This is consistent with previous literature that cited inadequate funding as a barrier to the development of prehospital care. Our responses went further to include barriers in education, lack of trained EMS personnel, and long distance patient transport. Although efforts are being made to improve trauma care in Jamaica and the rest of the world, there are still areas that need more attention and improvement.
| Abstract Number 29|| |
Antiphospholipid Syndrome with Disintegrin-Like and Metalloprotease Motif Resulting in Thrombotic Thrombocytopenic Purpura
Hallie H. Dolin, B. Abhijit, Saste, Mohammad Mobayad, James A. Auberle, Thomas J. Papadimos
Department of Anesthesiology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
Introduction: Antiphospholipid syndrome (aPLs) is an autoimmune disease that has the presence of antiphospholipid antibodies that cause hypercoagulability that can lead to venous and arterial thrombosis. The diagnostic criteria require one clinical event (i.e., thrombosis or pregnancy complication) and two antibody blood tests spaced at least 3 months apart that confirm the presence of either anti-b2-glycoprotein (an anticardiolipin) or lupus anticoagulant. Autoantibodies to a disintegrin-like and metalloprotease with thrombospondin type I motif, member 13 (ADAMTS 13) play an important role in the development of microthrombosis in thrombotic thrombocytopenic purpura (TTP) in patient with aPLs and make a serious disease even more life-threatening.
Case Summary: A 27-year old African-American female was admitted to the critical care service with shortness of breath (SOB) and malignant hypertension. She had progressive swelling of her lower extremities 2 weeks before admission and her SOB started 48 h before admission. She had a history of systemic lupus erythematosus (SLE) since the age of 13 with a resultant lupus nephritis (biopsy 2012, but no dialysis), aPLs, asthma, congestive heart failure in October 2017, a stroke in December 2017, and two previous miscarriages. Her home medications included mycophenolate, hydroxychloroquine, isosorbide, and labetalol and prednisone. She was antinuclear antibody (ANA) positive, lupus anticoagulant positive and anti-cardiolipin positive previous to admission, had a high anti-beta2-GP-I antibody titer (and an elevated brain natriuretic peptide). However, these antibodies were negative during this hospitalization. Her vital signs were blood pressure 204/131, respiratory rate 21, pulse 91, weight 113.4 kg, and body mass index 41.6 kg/m2, hemoglobin 5.5 g/dL, hematocrit 16.1%, white blood cells 2.8 × 109/L, and schistocytes on blood smear, platelets 48,000 × 109/L, haptoglobin <30 mg/dL, d-dimer 7884 mcg/L, fibrinogen 182 mg/dL, LDH 432 U/L, and creatinine 1.43 mg/dL (which rose to 2.32 mg/dL). Computed tomography of head was negative for recent hemorrhage but revealed an old right basal ganglia encephalomalacia consistent with previous ischemia/injury. Chest X-ray showed mild pulmonary edema, electrocardiography normal. Renal ultrasound (US) was negative. Transthoracic echo was normal. US revealed bilateral deep vein thromboses (DVTs) and she was placed on a heparin drip. Her BP was treated with a nicardipine drip and she was diuresed with butanamide. Methylprednisolone was also added at 250 mg per day. Within 24 h plasmapheresis commenced and continued until platelets were >150,000 × 109/L. The nicardipine drip was transitioned to labetalol, nifedipine XL, and hydralazine by mouth (PO). The heparin drip was transitioned to coumadin PO. Her acute kidney injury resolved with the anticoagulation. She remains in hospital with resolution of her DVTs. Methylprednisolone was transitioned to prednisone 1 mg/kg per day (until platelets normalized).
Case Discussion: There are several confounders in this case; she had a malignant hypertension that can lead to microangiopathic hemolysis and renal failure. Underlying SLE can also lead renal failure. SLE can also result in the development of an inhibitor resulting in ADAMTS 13 activity and TTP. She had high titers of anti-beta2-GP-I antibody titer in October 2017. Her aPLs antibody negativity during this admission could be secondary to chronic immunosuppression with steroids, mycophenolate, and hydroxychloroquine. Her renal failure, cerebral infarcts, and DVTs could have been secondary to aPLs. Given the absence of antiphospholipid antibodies, and in the absence of a histologic diagnosis, she did not meet criteria for catastrophic aPLs. Her pancytopenia has autoimmune causation. Therefore, her care necessitated treatment of each of these differential diagnoses.
Key Points: In life- and limb-threatening clotting disorders occurring in a short period and involving multiple organ systems, especially in patients with SLE and aPLs, TTP must be considered expeditiously and treated with anticoagulation, steroids, and plasmapheresis. As well as application of ancillary support methods such as antibiotic, transfusions, dialysis, and mechanical ventilation.
| References|| |
Peck GL, Garg M, Arquilla B, Gracias VH, Anderson III HL, Miller AC, et al.
The American College of Academic International Medicine 2017 consensus statement on international medical programs: Establishing a system of objective valuation and quantitative metrics to facilitate the recognition and incorporation of academic international medical efforts into existing promotion and tenure paradigms. Int J Crit Illn Inj Sci 2017;7:201-11.
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Anderson HL III, Arquilla B, Firstenberg MS, Garg M, Galwankar SC, Gracias VH, et al.
Mission statement of the American College of Academic International Medicine. Int J Crit Illn Inj Sci 2017;7:3-7.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]