Improving Care for Patients with Chronic Hepatitis B via Establishment of a Disease Registry.

In the United States, there is poor clinician adherence to the American Association for the Study of Liver Disease and other guidelines for chronic hepatitis B virus (CHB) management. This prospective cohort study evaluated whether a CHB registry improves CHB management. We included patients with CHB aged ≥ 18 years and who had a clinical encounter during September 1, 2016-August 31, 2019. We divided patients into three groups based on care received before September 1, 2019: 1) CIH: primary care clinician at HealthPartners Center for International Health, 2) GI: not CIH and seen by gastroenterology within previous 18 months, and 3) primary care (PC): not CIH and not seen by gastroenterology within previous 18 months. We created and implemented a CHB registry at CIH that allowed staff to identify and perform outreach to patients overdue for CHB management. Patients with laboratory testing (i.e., alanine transaminase and hepatitis B virus DNA) and hepatocellular carcinoma screening in the previous 12 months were considered up to date (UTD). We compared UTD rates between groups at baseline (September 1, 2019) and pilot CHB registry end (February 28, 2020). We evaluated 4,872 patients, 52% of whom were female: 213 CIH, 656 GI, and 4,003 PC. At baseline, GI patients were most UTD (69%) followed by CIH (51%) and PC (11%). At pilot end the percent of UTD patients at CIH increased by 11%, GI decreased by 10%, and PC was unchanged. CHB registry use standardized care and increased the percent of CHB patients with recent laboratory testing and HCC screening.

Cancer Screening in Refugees and Immigrants: A Global Perspective.

Clinicians in the United States are trained to screen for cancer based on patient age, gender, family history, and environmental risk factors such as smoking. These cancers generally include, breast, cervical, colon, lung, and prostate cancers. We know that refugees and other immigrants to the United States experience dramatic disparities in cancer screening. Additionally, many immigrants experience elevated risks from infection-attributable cancers due to their country or region of origin. U.S.- based clinicians may not routinely consider these unique risk factors. Although this article focuses on refugees, it is also intended to guide clinicians caring for other foreign-born immigrant groups living in the United States (hereafter referred to as "immigrants"). The document contains two sections: 1) special considerations for U.S. Preventive Services Task Force guidelines cancer screening recommendations in immigrants and 2) cancer risks and screening recommendation unique to certain immigrant groups. Disparities in cancer screening and prevalence are often greater for specific immigrant groups than for broader racial or ethnic groups (e.g., Black, Asian, Hispanic) into which they may fit. Disaggregation of data by language or country of origin is useful to identify such disparities and to design intervention opportunities within specific communities that are culturally distinct and/or who have different environmental exposures. Unique cancer risks and disparities in screening support a nuanced approach to cancer screening for immigrant and refugee populations, which is the focus of this narrative review.

Evaluation of a Program to Improve Linkage to and Retention in Care Among Refugees with Hepatitis B Virus Infection - Three U.S. Cities, 2006-2018.

An estimated 257 million persons worldwide have chronic hepatitis B virus (HBV) infection (1). CDC recommends HBV testing for persons from countries with intermediate to high HBV prevalence (≥2%), including newly arriving refugees (2). Complications of chronic HBV infection include liver cirrhosis and hepatocellular carcinoma, which develop in 15%-25% of untreated adults infected in infancy or childhood (3). HBV-infected patients require regular monitoring for both infection and sequelae. Several studies have evaluated initial linkage to HBV care for both refugee and nonrefugee immigrant populations (4-9), but none contained standardized definitions for either linkage to or long-term retention in care for chronic HBV-infected refugees. To assess chronic HBV care, three urban sites that perform refugee domestic medical examinations and provide primary care collaborated in a quality improvement evaluation. Sites performed chart reviews and prospective outreach to refugees with positive test results for presumed HBV infection during domestic medical examinations. Linkage to care (29%-53%), retention in care (11%-21%), and outreach efforts (22%-71% could not be located) demonstrated poor access to initial and ongoing HBV care. Retrospective outreach was low-yield. Interventions that focus on prospective outreach and addressing issues related to access to care might improve linkage to and retention in care.

Think Globally, Act Locally: Diagnosis and Management of Latent Tuberculosis in Minnesota's Foreign-Born Population.

Although the overall incidence and prevalence of tuberculosis (TB) is relatively low in the United States, the disease remains a significant problem among certain populations. Refugees and immigrants migrating from endemic countries are especially at risk for TB, and in Minnesota the majority of cases are found in this population. Given that the vast majority of these cases are caused by reactivated latent infection rather than primary infection, the key to disease control and prevention is the successful diagnosis and management of latent TB in immigrants and refugees from endemic areas. This article details the appropriate approach to screening, diagnosis and management of latent TB in the hope that all physicians are better equipped to aid our state's foreign-born population and improve public health.

Effect of country of origin, age, and body mass index on prevalence of vitamin D deficiency in a US immigrant and refugee population.

OBJECTIVE: To determine the prevalence of vitamin D deficiency (VDD) (25-hydroxyvitamin D level <20 ng/mL) and severe VDD (25[OH]D level <10 ng/mL) in a Minnesota immigrant and refugee population. PATIENTS AND METHODS: This retrospective study evaluated a cohort of adult immigrants and refugees seen at Health Partners Center for International Health in St Paul, Minnesota. Study participants were all patients seen from August 1, 2008, through July 31, 2009, with a first vitamin D screen (N=1378). Outcomes included overall prevalence of VDD and severe VDD. Covariates included country of origin, sex, age, month of test, and body mass index (BMI). RESULTS: Vitamin D deficiency was significantly more prevalent in our Minnesota clinic immigrant and refugee population than among US-born patients (827 of 1378 [60.0%] vs 53 of 151 [35.1%]; P<.001). Severe VDD was also significantly more prevalent (208 of 1378 [15.1%] vs 12 of 151 [7.9%]; P=.02). Prevalence of VDD varied significantly according to country of origin (42 of 128 Russian patients [32.8%] vs 126 of 155 Ethiopian patients [81.3%]; P<.001). The BMI correlated [corrected] with VDD (488 of 781 [62.5%] when BMI was ≥ 25 vs 292 of 520 [56.2%] when BMI was <25; P=.02). Vitamin D deficiency was present in 154 of 220 individuals (70.0%) 16 to 29 years old vs 123 of 290 (42.4%) in those older than 66 years (P<.001). CONCLUSION: Immigrants and refugees in a Minnesota clinic have a substantially higher rate and severity of VDD when compared with a US-born population. Country of origin, age, and BMI are specific risk factors for VDD and should influence individualized screening practices.

An innovative approach to teaching resuscitation skills.

We report the impact of a monthly educational exercise for residents that emphasized practical skills and equipment usage rather than knowledge of advanced cardiac life support (ACLS) protocols. Residents were divided into groups of approximately four that rotated through three stations. Each station included several objectives, most of which related to specific types of equipment. The exercise was held six times from July 2003 to June of 2004. Sixty-seven residents participated and completed a questionnaire prior to and following the exercise. The questionnaire elicited comfort level with basic tasks including using an automated external defibrillator (AED), attaching leads and paddles to read a cardiac rhythm, delivering unsynchronized shocks with monophasic and biphasic defibrillators and implementing the pacing function on a defibrillator. There were significant differences in the pre- and post-answers to each question. The largest difference was found in the question asking how comfortable participants were delivering unsynchronized shocks with a defibrillator. Importantly, responses for the question 'How comfortable are you being a code leader?' showed significant improvement. Simple skills such as attaching tubing to the oxygen tank, turning on the defibrillator and entering appropriate charge, or positioning paddles and monitor leads properly often caused significant difficulty. Cardiopulmonary arrests tend to generate anxiety among house staff, despite certification in ACLS and adequate knowledge of protocols. Exercises, such as the one presented here, will reduce anxiety by specifically addressing this skill. We conclude that residents benefit from additional teaching and practice in actual performance of basic skills used during cardiac arrests. Furthermore, our data demonstrate that comfort levels among house officers increase when they are given the opportunity to practice these skills.