Faculty Bibliography

BACKGROUND:Economic and social marginalization among American Indians and Alaska Natives (AI/ANs) results in higher chronic disease prevalence. Potential causal associations between toxic environmental exposures and adverse health outcomes within AI/AN communities are not well understood. OBJECTIVES/OBJECTIVE:This review examines epidemiological literature on exposure to toxicants and associated adverse health outcomes among AI/AN populations. METHODS:PubMed, Embase, Cochrane, Environment Complete, Web of Science Plus, DART, and ToxLine were searched for English-language articles. The following data were extracted: lead author's last name, publication year, cohort name, study location, AI/AN tribe, study initiation and conclusion, sample size, primary characteristic, environmental exposure, health outcomes, risk estimates, and covariates. RESULTS:About 31 articles on three types of environmental exposures met inclusion criteria: persistent organic pollutants (POPs), heavy metals, and open dumpsites. Of these, 17 addressed exposure to POPs, 10 heavy metal exposure, 2 exposure to both POPs and heavy metals, and 2 exposure to open dumpsites. Studies on the Mohawk Nation at Akwesasne; Yupik on St. Lawrence Island, Alaska; Navajo Nation; Gila River Indian Community; Cheyenne River Sioux; 197 Alaska Native villages; and 13 tribes in Arizona, Oklahoma, North Dakota, and South Dakota that participated in the Strong Heart Study support associations between toxicant exposure and various chronic conditions including cardiovascular conditions, reproductive abnormalities, cancer, autoimmune disorders, neurological deficits, and diabetes. DISCUSSION/CONCLUSIONS:The complex interplay of environmental and social factors in disease etiology among AI/ANs is a product of externally imposed environmental exposures, systemic discrimination, and modifiable risk behaviors. The connection between environmental health disparities and adverse health outcomes indicates a need for further study.

Active shooter incidents (ASI) have unfortunately become a common occurrence the world over. There is no country, city, or venue that is safe from these tragedies, and healthcare institutions are no exception. Healthcare facilities have been the targets of active shooters over the last several decades, with increasing incidents occurring over the last decade. People who work in healthcare have a professional and moral obligation to help patients. As concerns about the possibility of such incidents increase, how should healthcare institutions and healthcare professionals understand their responsibilities in preparation for and during ASI?

BACKGROUND:Breast cancer is the leading cause of female mortality in low-income and middle-income countries (LMICs). Early detection of breast cancer, either through screening or early diagnosis initiatives, led by community health workers (CHWs) has been proposed as a potential way to address the unjustly high mortality rates. We therefore document: (1) where and how CHWs are currently deployed in this role; (2) how CHWs are trained, including the content, duration and outcomes of training; and (3) the evidence on costs associated with deploying CHWs in breast cancer early detection. METHODS:We conducted a systematic scoping review and searched eight major databases, as well as the grey literature. We included original studies focusing on the role of CHWs to assist in breast cancer early detection in a country defined as a LMIC according to the World Bank. FINDINGS/RESULTS:16 eligible studies were identified. Several roles were identified for CHWs including awareness raising and community education (n=13); history taking (n=7); performing clinical breast examination (n=9); making onward referrals (n=7); and assisting in patient navigation and follow-up (n=4). Details surrounding training programmes were poorly reported and no studies provided a formal cost analysis. CONCLUSIONS:Despite the relative paucity of studies addressing the role of CHWs in breast cancer early detection, as well as the heterogeneity of existing studies, evidence suggests that CHWs can play a number of important roles in breast cancer early detection initiatives in LMICs. However, if they are to realise their full potential, they must be appropriately supported within the wider health system.

Background: Clinical exposure to Pediatric and Adolescent Gynecology (PAG) varies amongst residency programs 1,2. In areas such as PAG where clinical exposure may be limited, residents need solid evidence-based practice (EBP) skills to guide future independent practice. The OSCE format presents an opportunity to simulate a clinical scenario that residents may not encounter in their training, objectively assess performance, and increase learner motivation to continue building skills. This study evaluates resident performance on an EBP OSCE station based on a core PAG topic in order to evaluate its ability to provide program-level evaluation of the skills of evidence-based practice in PAG and provide actionable feedback to learners.
Method(s): A hybrid simulation/OSCE station was developed to assess core skills of EBP in the management of labial adhesions. A behaviorally anchored scoring checklist was developed for each component of the station and scored separately and independently by a single medical librarian and standardized patient. Mixed methods evaluation of performance by residents of all levels of residency training was done, focusing on quantitative analysis of EBP performance with thematic analysis of qualitative evaluation data.
Result(s): 30 Obstetrics and Gynecology residents participated in the PAG EBP OSCE station (9 PGY1, 10 PGY2, 6 PGY3, 5 PGY4). The overall mean score for all residents was 57% (+/- 18 SD). Mean scores by PGY increased between first and second year, but did not increase further in later years of training with the largest variation in performance in the PGY4 year (Figure 1). Thematic analysis of the qualitative feedback on residents' search strategies revealed useful insights at a programmatic level (Table 1). Upper level residents often used a less robust search strategy of the literature, instead opting for a database they had some familiarity with to guide their recommendations without searching for corroborating evidence or additional sources.
Conclusion(s): OSCE provides a feasible standardized way to observe, assess and encourage development of core EBP skills. A slight developmental trend was seen with improving scores among junior residents between the first and second years of training. However, this trend did not continue between the final years of training. The fact that scores did not increase linearly suggests that clinical training may not reinforce EBP skills. The importance of EBP skills is magnified in PAG where clinical exposure and experience amongst trainees may be limited. In addition to improving resident education in PAG, medical educators must continue to develop and implement interventions to teach and reinforce EBP skills to trainees to bring to future independent practice. [Formula presented] [Formula presented]
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OBJECTIVES/OBJECTIVE:Double fascicular transfer is argued to result in improved elbow flexion compared to the traditional ulnar fascicular transfer because it reinnervates both the biceps and the brachialis. This study seeks to determine if double fascicular transfer should be preferred over ulnar fascicular transfer to restore elbow flexion in patients with upper trunk brachial plexus injuries (BPI) by analyzing the current database of literature on the topic. METHODS:A systematic review was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting Medical Research Council (MRC) scores on individual patients undergoing ulnar fascicular transfer and double fascicular transfer (ulnar and median nerve fascicle donors). Patients were excluded if: age < 18 years old and follow-up <12 months. Demographics obtained include age, sex, extent of injury (C5-C6/C5-C7), preoperative interval, procedure type, and follow-up time. Outcomes included absolute MRC score and ability to achieve MRC score ≥3 and ≥4. Univariate and multivariate regression analyses were completed to evaluate predictors of postoperative outcomes. RESULTS:Eighteen studies (176 patients) were included for pooled analysis. Patients that underwent double fascicular transfer had a higher percentage of patients attain a MRC score ≥ 4 compared to ulnar fascicular transfer subjects (83.0% vs. 63.3%, p = .013). Double fascicular transfer was a predictor of achieving high MRC scores (OR = 2.829, p = .015). Multivariate analysis showed that procedure type was the only near significant predictor of ability to obtain MRC ≥4 (OR: 2.338, p = .054). CONCLUSIONS:This analysis demonstrates that double fascicular transfer is associated with superior postoperative outcomes and should be performed for restoring elbow flexion.

The Federal Bureau of Investigation (FBI) defines an active shooter as "an individual actively engaged in killing or attempting to kill people in a confined and populated area".¹ A study of newspaper articles and press releases identified 154 active shooter incidents (ASIs) in hospitals in the United States in the 12-year period 2000-2011.² ASIs were more common in larger hospitals, with 29% taking place in the emergency department (ED) and 19% in patient rooms. In 50% of the ASIs in an ED, the perpetrator used a security officer's gun.

INTRODUCTION/BACKGROUND:Prediction models for gestational hypertension and preeclampsia have been developed with data and assumptions from developed countries. Their suitability and application for low resource settings have not been tested. This review aimed to identify and assess the methodological quality of prediction models for gestational hypertension and pre-eclampsia with reference to their application in low resource settings. METHODS:Using combinations of keywords for gestational hypertension, preeclampsia and prediction models seven databases were searched to identify prediction models developed with maternal data obtained before 20 weeks of pregnancy and including at least three predictors (Prospero registration CRD 42017078786). Prediction model characteristics and performance measures were extracted using the CHARMS, STROBE and TRIPOD checklists. The National Institute of Health quality assessment tools for observational cohort and cross-sectional studies were used for study quality appraisal. RESULTS:We retrieved 8,309 articles out of which 40 articles were eligible for review. Seventy-seven percent of all the prediction models combined biomarkers with maternal clinical characteristics. Biomarkers used as predictors in most models were pregnancy associated plasma protein-A (PAPP-A) and placental growth factor (PlGF). Only five studies were conducted in a low-and middle income country. CONCLUSIONS:Most of the studies evaluated did not completely follow the CHARMS, TRIPOD and STROBE guidelines in prediction model development and reporting. Adherence to these guidelines will improve prediction modelling studies and subsequent application of prediction models in clinical practice. Prediction models using maternal characteristics, with good discrimination and calibration, should be externally validated for use in low and middle income countries where biomarker assays are not routinely available.

BACKGROUND:A severe neurological disorder, Guillain-Barré syndrome (GBS) is the leading cause of acute flaccid paralysis. Enhanced surveillance of GBS in Latin America and the Caribbean (LAC) following the 2015-2016 Zika virus (ZIKV) epidemic presents an opportunity to estimate, for the first time, the regional incidence of GBS. METHODS AND FINDINGS/RESULTS:For this systematic review and meta-analysis, we searched nine scientific databases and grey literature from January 1, 1980 to October 1, 2018. Sources with primary data on incident GBS cases in LAC within a well-defined population and timeframe, published in English, Spanish, Portuguese, or French, were included. We calculated the annual GBS incidence rates (IRs) and 95% confidence intervals (CIs) for each source based on published data. Following an assessment of heterogeneity, we used random-effects meta-analysis to calculate the pooled annual IR of GBS. The study is registered with PROSPERO, number CRD42018086659. Of the 6586 initial citation hits, 31 were eligible for inclusion. Background annual GBS IRs in Latin America ranged from 0.40 in Brazil to 2.12/100,000 in Chile. The pooled annual IR in the Caribbean was 1.64 (95% CI 1.29-2.12, I2<0.01, p = 0.44). During the ZIKV epidemic, GBS IRs ranged from 0.62 in Mexico to 9.35/100,000 in Martinique. GBS increased 2.6 (95% CI 2.3-2.9) times during ZIKV and 1.9 (95% CI 1.1-3.4) times during chikungunya outbreaks over background rates. A limitation of this review is that the studies included employed different methodologies to find and ascertain cases of GBS, which could contribute to IR heterogeneity. In addition, it is important to consider that data on GBS are lacking for many countries in the region. CONCLUSIONS:Background IRs of GBS appear to peak during arboviral disease outbreaks. The current review contributes to an understanding of the epidemiology of GBS in the LAC region, which can inform healthcare system planning and preparedness, particularly during arboviral epidemics. TRIAL REGISTRATION/BACKGROUND:Registered with PROSPERO: CRD42018086659.

Objective: The purpose of this study was to assess the association between extent of brachial plexus injury and shoulder abduction/external rotation outcomes after spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer. Methods: A systematic review of the literature was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting outcomes on patients undergoing SAN to SSN nerve transfer. Patients were excluded for the following reasons: age under 18, nerve transfer for reanimation of the shoulder other than SAN to SSN, and less than 12 months of follow-up postoperatively. Pooled analysis was performed, and primary outcomes were Medical Research Council (MRC) score and range of motion (ROM) for shoulder abduction and external rotation. Univariate logistic regression analysis was used to assess the association between extent of brachial plexus injury and shoulder abduction/external rotation outcomes after SAN to SSN transfer. A multivariate logistic regression analysis model including age, injury to surgery interval, and extent of injury as factors was also created. Results: Univariate logistic regression analysis showed greater extent of injury to be a predictor of poorer shoulder abduction outcomes (OR: 0.502; 95% CI: 0.260-0.971, p = 0.040). Multivariate logistic regression analysis confirmed this association (OR: 0.55; 95% CI: 0.236-0.877, p = 0.019). Extent of injury was not significantly associated with external rotation outcomes on univariate analysis (OR: 0.435; 95% CI: 0.095-1.995, p = 0.284) or multivariate analysis (OR: 0.445; 95% CI: 0.097-2.046, p = 0.298). Age and injury to surgery interval were not significantly associated with postoperative outcomes. Conclusions: More extensive brachial plexus injuries are associated with inferior outcomes after SAN to SSN transfer. A potential explanation for this finding includes lost contribution of muscles from the shoulder girdle that receive innervation from outside of the upper brachial plexus. The relationship between extent of injury and postoperative outcomes is important to recognize when determining and discussing operative intervention with patients.

OBJECTIVE:A review of the implementation outcomes of clean cookstove use, and its effects on blood pressure (BP) in low-income and middle-income countries (LMICs). DESIGN/METHODS:Systematic review of studies that reported the effect of clean cookstove use on BP among women, and implementation science outcomes in LMICs. DATA SOURCES/METHODS:We searched PubMed, Embase, INSPEC, Scielo, Cochrane Library, Global Health and Web of Science PLUS. We conducted searches in November 2017 with a repeat in May 2018. We did not restrict article publication date. ELIGIBILITY CRITERIA FOR SELECTING STUDIES/UNASSIGNED:We included only studies conducted in LMICs, published in English, regardless of publication year and studies that examined the use of improved or clean cookstove intervention on BP. Two authors independently screened journal article titles, abstracts and full-text articles to identify those that included the following search terms: high BP, hypertension and or household air pollution, LMICs, cookstove and implementation outcomes. RESULTS:Of the 461 non-duplicate articles identified, three randomised controlled trials (RCTs) (in Nigeria, Guatemala and Ghana) and two studies of pre-post design (in Bolivia and Nicaragua) met eligibility criteria. These articles evaluated the effect of cookstove use on BP in women. Two of the three RCTs reported a mean reduction in diastolic BP of -2.8 mm Hg (-5.0, -0.6; p=0.01) for the Nigerian study; -3.0 mm Hg; (-5.7, -0.4; p=0.02) for the Guatemalan study; while the study conducted in Ghana reported a non-significant change in BP. The pre-post studies reported a significant reduction in mean systolic BP of -5.5 mm Hg; (p=0.01) for the Bolivian study, and -5.9 mm Hg (-11.3, -0.4; p=0.05) for the Nicaraguan study. Implementation science outcomes were reported in all five studies (three reported feasibility, one reported adoption and one reported feasibility and adoption of cookstove interventions). CONCLUSION/CONCLUSIONS:Although this review demonstrated that there is limited evidence on the implementation of clean cookstove use in LMICs, the effects of clean cookstove on BP were significant for both systolic and diastolic BP among women. Future studies should consider standardised reporting of implementation outcomes.