A systematic review of effective strategies for chronic disease management in humanitarian settings; opportunities and challenges.

Large number of people with non-communicable diseases (NCDs) face barriers to adequate healthcare in humanitarian settings. We conducted a systematic literature review in MEDLINE/PubMed, Web of Science, EMBASE/DARE, Cochrane, and grey literature from 1990 to 2021 to evaluate effective strategies in addressing NCDs (diabetes, cardiovascular diseases, COPD, cancer) in humanitarian settings. From 2793 articles, 2652 were eliminated through title/abstract screening; 141 articles were reviewed in full; 93 were eliminated for not meeting full criteria. Remaining 48 articles were reviewed qualitatively to assess populations, settings, interventions, outcome, and efficacy and effectiveness; 38 studies addressed treatments, 9 prevention, and 7 epidemiology. Prevention studies broadly addressed capacity-building. Treatment and epidemiology studies largely addressed hypertension and diabetes. Interventions included web-based/mobile health strategies, pharmacy-level interventions, portable imaging, and capacity building including physical clinics, staff training, forging collaborations, guideline development, point-of-care labs, health promotion activities, EMR, and monitoring interventions. Collaboration between academia and implementing agencies was limited. Models of care were largely not well-described and varied between studies due to contextual constraints. Barriers to interventions included financial, logistical, organizational, sociocultural, and security. Cancer care is significantly understudied. Simplified care models adapted to contexts and program evaluations of implemented strategies could address gaps in applied research. Inherent challenges in humanitarian settings pose unavoidable perils to evidence generation which requires a shift in research mindset to match aspirations with practicality, research collaborations at the inception of projects, reworking of desired conventional level of research evidence considering resource-intense constraints (HR, time, cost), and adapted research tools, methods, and procedures.

African-Americans Are Less Frequently Assessed For Hereditary Colon Cancer.

INTRODUCTION: Colorectal cancer (CRC) is the third most common malignancy in the United States and disproportionately affects African-Americans. Approximately 5-10% of CRC results from hereditary cancer syndromes. A detailed family history is recommended as an initial component of cancer risk assessment to help determine initiation, frequency, screening method and genetic counselling referral. This study evaluated the rate of hereditary CRC risk assessment in African-American and white patients. METHODS: A chart review of all patients referred for CRC screening in a university gastroenterology clinic during a 3 month period was performed. Patient self-described race/ethnicity, gender, age, documentation of multi-generational family medical history (3+ generations) were obtained. Amsterdam II Criteria, Bethesda Criteria and Colorectal Cancer Risk Assessment Tool were used to determine which patients with family histories should receive referrals for genetic counselling. Statistical analysis was performed using Fisher's Exact Test with significance set at p < 0.05. The study was IRB approved. RESULTS: 872 medical records were reviewed, including 452 African-American (276 females, 176 males; mean age 60.2), 263 White (123 females, 140 males; mean age 59.4), 45 Hispanic, and 42 Asian. Multi-generational family history was obtained from 143 (16.4%); 62 African-American (13.7%; 47 females, 15 males), 58 White (22.1%; 37 females, 21 whites), 3 Hispanic (6.7%), and 4 Asian (9.5%). There was a significant difference (p = 0.0050) in the rate of detailed family history in African-Americans and whites. However, African-Americans and Whites similarly qualified for genetic counselling when family history was obtained (p = 0.7915); 58.1% African-Americans (36; 30 females, 6 males) and 50% Whites (29: 19 females, 10 males) qualified for genetic counselling. Overall referral rate to genetic counselling was 16.5% with no significant difference (p = 0.7586) between African-Americans and whites. CONCLUSIONS: CRC risk assessment with detailed family medical history was inconsistently performed in all patients. There was significantly lower rate of obtaining multi-generational family medical histories in African-Americans. Referrals of all patients for genetic counselling and testing were also insufficient. Appropriate identification of individuals at increased risk for hereditary cancer syndromes, particularly African-Americans, is critical to prevention, early detection, and treatment of CRC and improving disparities in care.

Gastrointestinal and Hepatic Manifestations of COVID-19: Evolving Recognition and Need for Increased Understanding in Vulnerable Populations.

The novel coronavirus, SARS-CoV-2, has caused a global pandemic with high morbidity and mortality. It was first observed to cause a severe acute respiratory syndrome. However, gastrointestinal and hepatic manifestations have been increasingly recognized. Gastrointestinal symptoms include diarrhea, epigastric pain, nausea, and vomiting. Diarrhea is the most common GI manifestation of SARS-CoV-2 and can present without or without respiratory symptoms. Patients with GI symptoms have been associated with longer duration of illness and may be associated with more severe illness. Mechanism of diarrhea is thought to be related to direct viral cytotoxicity occurring when the SARS-CoV-3 enters GI cells via the ACE-2 receptor. Inflammatory response and cytokine release likely contributes to symptoms. SARS-CoV-2 can cause hepatic injury. Studies have shown mild to moderate elevation of liver enzymes. The pattern of liver abnormalities can be hepatocellular, cholestatic or mixed. Patients with severe infection have significantly higher rates of liver injury and worse outcomes. Proposed mechanisms for injury include immune mediated systemic inflammatory response, direct cytotoxicity from viral replication and hypoxia-reperfusion dysfunction. Recent data suggests that GI and hepatic injury may be under-recognized manifestation of SARS-CoV-2 infection. Patients with diarrhea and liver disease may have a worse prognosis. The rapidly evolving literature continues to reveal a growing body of information which enables updated guidance for management. More investigation is needed which focuses on vulnerable patients, including the elderly, those with underlying illness, as well as, racial and ethnic minorities.

Diet-induced oxalate nephropathy from excessive nut and seed consumption.

Oxalate is a metabolite consumed in nuts, beans and leaves, and excreted in urine. Oxalosis can cause nephropathy. We describe a rare case of a high-oxalate diet intended for irritable bowel syndrome (IBS) treatment causing oxalate nephropathy. A 59-year-old woman with a history of controlled hypertension presented with creatinine 1.8 mg/dL, increased from baseline 1.3 mg/dL. She denied recent illness, urinary stones, medication adjustments, herbal supplements and non-steroidal anti-inflammatory drugs use. Diet included six tablespoons of chia seeds and five handfuls of almonds daily to manage IBS symptoms. Her electrolytes, urinalysis and renal ultrasound were unremarkable. Her 24-hour urine output revealed increased oxalate and low citrate. Renal biopsy showed glomerulosclerosis, fibrosis and calcium oxalate deposition. She switched to a low-oxalate diet, with improvement in laboratory markers. An earlier dietary history could have raised concern for oxalosis prior to renal biopsy. Providers should be trained to identify at-risk patients and provide appropriate dietary counselling.

Apetamin Hepatotoxicity: Potential Consequences of Purchasing a Body Enhancement Drug Off the Internet.

We report Apetamin (cyproheptadine lysine and vitamin syrup), a non-US Food and Drug Administration-approved weight gain supplement, causing drug-induced autoimmune hepatitis. A 40-year-old previously healthy woman presented with fatigue, right-sided abdominal discomfort, and jaundice 6 weeks after starting Apetamin, which she learned from social media for figure augmentation. Labs were significant for elevated transaminases, positive smooth muscle antibody, and increased immunoglobulins. Biopsy indicated drug-induced autoimmune hepatitis. Symptoms improved with prednisone, azathioprine, and stopping Apetamin which contains cyproheptadine, a known hepatotoxin. The case reveals the influence of social media and its impact on health and the importance of a complete drug history.

Active design in affordable housing: A public health nudge.

This pilot study investigates the impact of active design (AD) strategies on physical activity (PA) among adults living in two Leadership in Energy and Environmental Design (LEED) certified affordable housing developments in the South Bronx, New York. One building incorporates LEED Innovation in Design (ID) Credit: Design for Health through Increased Physical Activity. Tenants in an affordable housing building (AH) incorporating active design strategies completed PA self-assessments at their lease signing and one year later in 2015. Trained research assistants obtained body measurements. Residents of neighboring non-AD affordable housing (MCV) served as a comparison. Thirty four adults were recruited from AH and 29 from MCV, retention was 56% (n = 19) and 52% (n = 15) respectively at one year. The two groups' body mass index (BMI) and high-risk waist-to-hip ratio (WHR) were not statistically significantly different when analyzed as continuous variables, although BMI category had a greater decline at AH than at MCV (p = 0.054). There was a 31.5% increase in AH participants meeting MPA requirements and a statistically significant improvement in females (p = 0.031); while there was no change in the MCV participants overall or when stratified by gender. AH participants were significantly more likely to have reported increased stair use and less likely to have reported no change or decreased stair use than participants from MCV participants (p = 0.033). Housing has a role in individual health outcomes and behavior change, broad adoption of active design strategies in affordable housing is warranted to improve physical activity measures.

Cervical Cancer Screening Among Homeless Women of New York City Shelters.

Introduction Homeless persons have minimal opportunities to complete recommended cancer screening. The rates and predictors of cervical cancer screening are understudied among homeless women in the US. Methods We enrolled 297 homeless women 21-65 years old residing in 6 major New York City shelters from 2012 to 2014. We used a validated national survey to determine the proportion and predictors of cervical cancer screening using cytology (Pap test). Results Mean age was 44.72 (±11.96) years. Majority was Black, heterosexual, single, with high school or lower education; 50.9 % were smokers and 41.7 % were homeless more than a year. Despite a 76.5 % proportion of self-reported Pap test within the past 3 years, 65 % of women assumed their Pap test results were normal or did not get proper follow up after abnormal results. Forty-five-point-nine percent of women did not know about frequency of Pap test or causes of cervical cancer. Lower proportion of up-to-date Pap test was associated with lack of knowledge of recommended Pap test frequency (p < 0.01) and relationship between HPV and an abnormal Pap test (p < 0.01). Conclusions Self-reported Pap testing in homeless women was similar to a national sample. However, the majority of women surveyed were not aware of their results, received limited if any follow up and had significant education gaps about cervical cancer screening. We recommend improved counseling and patient education, patient navigators to close screening loops, and consideration of alternative test-and-treat modalities to improve effective screening.

Human Papillomavirus Knowledge and Attitude among Homeless Women of New York City Shelters.

BACKGROUND: Human papillomavirus (HPV) has not been studied among homeless women in the United States. We assessed knowledge and attitudes regarding HPV infection and the HPV vaccine among homeless women. METHODS: We enrolled 300 homeless women age 19 to 65 residing in multiple New York City shelters from 2012 to 2014. We used a national survey to collect HPV data. RESULTS: Mean age was 44.7 ± 12.16 years. The majority were Black, heterosexual, and single; 50.6% were smokers. Almost all HPV knowledge and attitudes data were considerably below the national averages; 41.9% never heard of HPV. Only 36.5% knew that HPV is a sexually transmitted disease; 41.5% knew that HPV causes cervical cancer; and only 19.5% and 17.3% received provider counseling regarding HPV testing and vaccine, respectively. Among participants, 65.4% reported that they would vaccinate their eligible daughters for HPV. Lower rates of up-to-date Pap tests were associated with a lack of knowledge regarding relationship between HPV and abnormal Pap test (p < .01). CONCLUSIONS: We recommend improved HPV counseling by providers during any clinical encounter to reduce missed opportunities, coupled with employing patient teaching coach or navigators to improve health literacy and to connect patients to services regarding HPV and cervical cancer.

Breast cancer screening among homeless women of New York City shelter-based clinics.

BACKGROUND: Millions of Americans experience homelessness annually. Data on breast cancer screening among homeless women is extremely limited. METHODS: We performed a retrospective study evaluating 100 female patients 50 to 74 years old with at least three visits to two major New York City shelter-based clinics between 2010 and 2012 to evaluate and compare rates and predictors of mammograms in homeless and low-income domicile patients. RESULTS: Of those we included, 44% were homeless with majority Black and Hispanic. Mean age was 59.28 (±5.84) years. The majority were insured, with 44% smokers and 87% with chronic illnesses. Rates of mammogram within past 2 years were 59% in homeless and 57.1% in low-income domicile patients; 53% did not know the results of their mammogram. Homeless and domicile patients received equal provider counseling. Homeless women were more likely to be uninsured (p < .01). Domicile patients were more likely to have a chronic illness (p < .01). A history of mental illness or substance abuse was not different between the two groups. In logistic regression, provider counseling predicted mammogram (odds ratio, 31.69; 95% CI, 3.76-266.8); race, insurance status, housing status, and history of mental illness or substance abuse did not. CONCLUSION: The overall low rate of mammogram in this population compared with the national average is alarming. We suggest trained patient navigators to address social barriers and tailored patient education and counseling at any clinical encounter to address misconceptions, along with broader structural approaches to address homelessness.

Colorectal cancer screening among the homeless population of New York City shelter-based clinics.

OBJECTIVES: We determined colorectal cancer (CRC) screening rates, predictors, and barriers in 2 major New York City shelter-based clinics. METHODS: We extracted screening rates, sociodemographic characteristics, and factors associated with homelessness from medical records of domiciled and homeless patients aged 50 years and older (n = 443) with at least 3 clinic visits between 2010 and 2012. RESULTS: The majority of patients were African American or Hispanic, 76% were male, and 60.7% were homeless (mean = 2.4 years; SD = 2.8 years). Domiciled patients were more likely than homeless patients to be screened (41.3% vs 19.7%; P < .001). Homeless and domiciled patients received equal provider counseling, but more homeless patients declined screening (P < .001). In logistic regression, gender, race, duration of homelessness, insurance status, substance and alcohol abuse, chronic diseases, and mental health were not associated with screening, but housing, provider counseling, and older age were. CONCLUSIONS: Proposed interventions to improve CRC screening include respite shelter rooms for colonoscopy prepping, patient navigators to help navigate the health system and accompany patients to and from the procedure, counseling at all clinical encounters, and tailored patient education to address misconceptions.