A 50-year-old refugee woman with a lithopedion and a lifetime of trauma: a case report.

BACKGROUND: Lithopedion is a term that refers to a fetus that has calcified or changed to bone. The calcification may involve the fetus, membranes, placenta, or any combination of these structures. It is an extremely rare complication of pregnancy and can remain asymptomatic or present with gastrointestinal and/or genitourinary symptoms. CASE PRESENTATION: A 50-year-old Congolese refugee with a nine-year history of retained fetus after a fetal demise was resettled to the United States (U.S.). She had chronic symptoms of abdominal pain and discomfort, dyspepsia, and gurgling sensation after eating. She experienced stigmatization from healthcare professionals in Tanzania at the time of the fetal demise and subsequently avoided healthcare interaction whenever possible. Upon arrival to the U.S., evaluation of her abdominal mass included abdominopelvic imaging which confirmed the diagnosis of lithopedion. She was referred to gynecologic oncology for surgical consultation given intermittent bowel obstruction from underlying abdominal mass. However, she declined intervention due to fear of surgery and elected for symptom monitoring. Unfortunately, she passed away due to severe malnutrition in the context of recurrent bowel obstruction due to the lithopedion and continued fear of seeking medical care. CONCLUSION: This case demonstrated a rare medical phenomenon and the impact of medical distrust, poor health awareness, and limited access to healthcare among populations most likely to be affected by a lithopedion. This case highlighted the need for a community care model to bridge the gap between the healthcare team and newly resettled refugees.

Refugee Births and the Migrant Health Effect in Syracuse NY.

OBJECTIVES: In Syracuse, NY among 5998 births in a 3-year period (2017-2019), 24% were to foreign-born women, among whom nearly 5% were refugees from the Democratic Republic of the Congo and Somalia. The impetus for the study was to identify potential risk factors and birth outcomes of refugee women, other foreign-born women, and US born women to inform care. METHODS: This study reviewed 3 years of births (2017-2019) in a secondary database of births in Syracuse, New York. Data reviewed included maternal demographics, natality, behavioral risk factors (e.g., drug use, tobacco use), employment, health insurance, and education. RESULTS: In a logistic regression model controlling for race, education, insurance status, employment status, tobacco use and illicit drug use, compared to US born mothers, refugees (OR 0.45, 95% CI 0.24-0.83) and other foreign born (OR 0.63, 95% CI 0.47-0.85) had significantly fewer low birth weight births. CONCLUSION: The results of this study supported the "healthy migrant effect," a concept that refugees have fewer low birth weight (LBW) births, premature births, and cesarean section deliveries than US born women. This study adds to the literature on refugee births and the healthy migrant effect.

Community suicide rates and related factors within a surveillance platform in Western Kenya.

BACKGROUND: Suicide is an important contributor to the burden of mental health disorders, but community-based suicide data are scarce in many low- and middle-income countries (LMIC) including Kenya. Available data on suicide underestimates the true burden due to underreporting related to stigma and legal restrictions, and under-representation of those not utilizing health facilities. METHODS: We estimated the cumulative incidence of suicide via verbal autopsies from the Health and Demographic Surveillance System (HDSS) in Kisumu County, Kenya. We then used content analysis of open history forms among deaths coded as accidents to identify those who likely died by suicide but were not coded as suicide deaths. We finally conducted a case-control study of suicides (both verbal autopsy confirmed and likely suicides) compared to accident-caused deaths to assess factors associated with suicide in this HDSS. RESULTS: A total of 33 out of 4306 verbal autopsies confirmed suicide as the cause of death. Content analysis of a further 228 deaths originally attributed to accidents identified 39 additional likely suicides. The best estimate of suicide-specific mortality rate was 14.7 per 100,000 population per year (credibility window = 11.3 - 18.0). The most common reported method of death was self-poisoning (54%). From the case-control study interpersonal difficulties and stressful life events were associated with increased odds of suicide in both confirmed suicides and confirmed combined with suspected suicides. Other pertinent factors such as age and being male differed depending upon which outcome was used. CONCLUSION: Suicide is common in this area, and interventions are needed to address drivers. The twofold increase in the suicide-specific mortality rate following incorporation of misattributed suicide deaths exemplify underreporting and misclassification of suicide cases at community level. Further, verbal autopsies may underreport suicide specifically among older and female populations.

Integrating the social determinants of health into two interprofessional courses: Findings from a pilot study.

Five colleges and universities in Upstate New York, United States, created the 'Route-90 Collaborative' to support faculty implementing the Institute of Medicine's (IOM) Framework for Educating Health Professionals to Address the Social Determinants of Health. The two courses described herein used a flipped classroom approach in which students from 14 different nations were responsible for facilitating individual classes. This descriptive study used an educational intervention in two interprofessional courses - reproductive health and global health - based on the IOM Framework into two courses. The evaluation used quantitative and open-ended text response data from students. Course evaluations indicated the students found the courses helped them to learn more about health issues and service delivery in various countries, expand their knowledge base on sociocultural and ecological influences on health care, and broaden their perspectives on various health topics so they will be able to provide higher quality healthcare. Although this is the first effort of our Collaborative to implement the Framework, given the student feedback, we believe implementing the Framework in various courses has the potential to enhance healthcare service delivery and reduce the negative impact of social determinants of health.

Social network.

The Better Care Exchange is a social network for health and social care professionals that enables information and knowledge sharing on good practice and better integrated care, and the implementation of Better Care Fund plans.

The experiences of community health workers when communicating with refugees about COVID-19 vaccines in Syracuse, NY: A qualitative study.

Background: Refugees are among the most health-vulnerable members of society. Despite the importance of vaccination to mitigate the risks associated with COVID-19 infection, ensuring adequate access and uptake of the COVID-19 vaccine remains a pressing concern for refugee populations. Research has suggested that community-oriented approaches and open communication with trusted individuals are essential to address this challenge. Vaccine outreach efforts were performed in Syracuse, NY, by Community Health Workers (CHWs) as trusted refugee community members. This study explored CHWs' experiences during vaccine outreach and perceptions about COVID-19 vaccine hesitancy and acceptance among refugees, including barriers and facilitators to vaccination. Methods: A qualitative study was performed using thematic analysis following six semi-structured interviews with CHWs. Results: Four main themes supported by 16 sub-themes were extracted. CHWs described the (1) diverse beliefs and attitudes of refugees by ethnic group, with most having low vaccine acceptance at first. (2) Barriers included contextual barriers, lack of awareness, misinformation, and withdrawal when forced from vaccine mandates. However, CHWs also identified numerous (3) facilitators to vaccination, including the internal processing and eventual vaccine acceptance, supported by external messaging by CHWs and time. Culturally sensitive intervention strategies occurred through (4) CHW team efforts and their provision of reliable information to refugee clients, with openness and over time. The team efforts of CHWs significantly contributed to refugee acceptance and uptake of the COVID-19 vaccine. Conclusions: This study revealed how the refugee population changed their belief towards the COVID-19 vaccine through trust, time, and reliable information provided by CHWs and describes culturally sensitive strategies for vaccine uptake by refugees. CHWs' reflection on COVID-19 vaccine hesitancy and acceptance among refugees during outreach efforts is an essential perspective when implementing future public health interventions.

Deployment of Rotavirus Vaccine in Western Kenya Coincides with a Reduction in All-Cause Child Mortality: A Retrospective Cohort Study.

Rotavirus is an important cause of fatal pediatric diarrhea worldwide. Many national immunization programs began adding rotavirus vaccine following a 2009 World Health Organization recommendation. Kenya added rotavirus vaccine to their immunization program at the end of 2014. From a cohort of 38,463 children in the Kisumu health and demographic surveillance site in western Kenya, we assessed how the implementation of the rotavirus vaccine affected mortality in children under 3 years of age. Following its introduction in late 2014, the span of rotavirus vaccine coverage for children increased to 75% by 2017. Receiving the rotavirus vaccine was associated with a 44% reduction in all-cause child mortality (95% confidence interval = 28-68%, p < 0.0001), but not diarrhea-specific mortality (p = 0.401). All-cause child mortality declined 2% per month following the implementation of the rotavirus vaccine (p = 0.002) among both vaccinated and unvaccinated children, but diarrhea-specific mortality was not associated with the implementation of the rotavirus vaccine independent of individual vaccine status (p = 0.125). The incidence of acute diarrhea decreased over the study period, and the introduction of the rotavirus vaccine was not associated with population-wide trends (p = 0.452). The receipt of the rotavirus vaccine was associated with a 34% reduction in the incidence of diarrhea (95% confidence interval = 24-43% reduction). These results suggest that rotavirus vaccine may have had an impact on all-cause child mortality. The analyses of diarrhea-specific mortality were limited by relatively few deaths (n = 57), as others have found a strong reduction in diarrhea-specific mortality. Selection bias may have played a part in these results-children receiving rotavirus vaccine were more likely to be fully immunized than children not receiving the rotavirus vaccine.

Spina Bifida Global Learning Collaborative: Educating the next generation of clinicians, researchers, and advocates.

PURPOSE: This project aimed to launch an international learning community to guide the development of a spina bifida (SB) curriculum for global health trainees. METHODS: Using a descriptive study design, a convenience sample of SB curricula were identified in 2022-23 by members of the Spina Bifida World Congress Outreach Committee and evaluated during a series of monthly Zoom calls to discuss SB education in a global health context. Participants included (1) leadership from the ReachAnother Foundation, (2) invited panelists from the Spina Bifida World Congress Global Health Symposium, and (3) global health students and preceptors. Education initiatives in Ethiopia, Sweden, Argentina, Ecuador, and the United States were evaluated vis-à-vis format and content. RESULTS: All of the education initiatives referenced the framework of the World Health Organization International Classification of Functioning, Disability and Health. Formats varied and included both virtual and interactive workshops, print materials, videos, and guides for small group discussion. Content addressed four domains: Folate Prevention, Neurosurgical Training, After Care, and Data Collection. A multidisciplinary approach, partnerships with families, and workforce pipeline training were identified as guiding themes for educating the next generation of SB researchers and clinicians in global health settings. CONCLUSION: The Spina Bifida Global Learning Collaborative is a transnational group of advocates, clinicians, and investigators whose mission is the advancement of SB-related global health education. Lessons learned from the collaborative are being leveraged to develop a global health curriculum for learners, which may improve services for individuals with SB around the globe.

Adverse effects of Lugol's iodine: Heart failure in a patient with subcutaneous phycomycosis from a resource-limited setting.

Subcutaneous phycomycosis becomes a chronic, debilitating condition if left untreated. Treatment includes oral antifungal therapy, though oral potassium iodide has been used in resource-limited settings. Lugol's iodine has been an effective substitute, but little is known about its safety. We report a case of subcutaneous phycomycosis complicated by heart failure during treatment with Lugol's iodine. We review subcutaneous phycomycosis, iodine-mediated cardiotoxicity, as well as social determinants of health relevant to our case, suggesting that Lugol's iodine may only be an effective treatment with proper dosing and long-term monitoring.

Vaccine hesitancy in the refugee, immigrant, and migrant population in the United States: A systematic review and meta-analysis.

Refugees, immigrants, and migrants (RIM) in the United States (US) have been identified as an underimmunized population prior to the COVID-19 pandemic. Vaccine acceptance is critical to combat the public health threat incited by COVID-19 and other vaccine-preventable disease. To better understand escalating vaccine hesitancy among US RIM, a comprehensive evaluation of the problem and solutions is necessary. In this systematic review, we included 57 studies to describe vaccination rates, barriers, and interventions addressing vaccine hesitancy over the past decade. Meta-analysis was performed among 22 studies, concluding that RIM represent an underimmunized population compared to the general US population. Narrative synthesis and qualitative methods were used to identify critical barriers, including gaps in knowledge, poor access to medical care, and heightened distrust of the medical system. Our results demonstrate the need for effective, evidence-based interventions to increase vaccination rates among diverse RIM populations.

COVID-19 vaccination intention and behavior in a large, diverse, U.S. refugee population.

INTRODUCTION: Refugees often face increased risk of exposure to COVID-19 due to their disproportionate representation in the essential workforce and crowded household conditions. There is a paucity of data about risk factors for under-immunization for COVID-19 among refugees. METHODS: Refugees were surveyed in two phases that corresponded to before and after wide availability of COVID-19 vaccines. Participants were asked about their attitudes, and perceptions about COVID-19, previous acceptance of vaccines, sources utilized to obtain trusted health information, and intent to get vaccinated. The overall participant vulnerability was assessed using the social vulnerability index. In-depth semi-structured interviews were completed with key stakeholders through snowball sampling. RESULTS: Of 247 refugees, 244 agreed to participate in the initial survey. Among those, 140 (57.4%) intended to get vaccinated, 43 (17.6%) were unsure, and 61 (25%) did not intend to get vaccinated. In the follow up survey, all 215 who were reached, agreed to provide information about their vaccination status. Among those respondents, 141 (65.6%) were either vaccinated or expressed intent to do so, and 74 (34.4%) remained hesitant. We did not observe any significant correlation between socio-demographic variables, country of origin, and vaccination status/intent. Among those who initially intended to get vaccinated, nearly 1 in 5 changed their mind and decided to forego vaccination, and among those who initially did not plan getting vaccinated, 1 in 3 changed their mind and got vaccinated. Fears related to the vaccine, concerns that the vaccine is religiously prohibited, "wait and see" how others did with the vaccine, communication and transportation barriers were commonly cited as reason not to get vaccinated. CONCLUSIONS: Over a third of refugees in our study were hesitant to get vaccinated. Refugees desired additional education about the benefits and safety of vaccines along with easier access to vaccination clinics in their communities.

Invasive bacterial and fungal infections among hospitalized HIV-infected and HIV-uninfected adults and adolescents in northern Tanzania.

BACKGROUND: few studies describe patterns of human immunodeficiency virus (HIV) co-infections in African hospitals in the antiretroviral therapy (ART) era. METHODS: we enrolled consecutive admitted patients aged ≥ 13 years with oral temperature of ≥ 38.0°C during 1 year in Moshi, Tanzania. A standardized clinical history and physical examination was done and hospital outcome recorded. HIV antibody testing, aerobic and mycobacterial blood cultures, and malaria film were performed. HIV-infected patients also received serum cryptococcal antigen testing and CD4(+) T lymphocyte count (CD4 cell count). RESULTS: of 403 patients enrolled, the median age was 38 years (range, 14-96 years), 217 (53.8%) were female, and 157 (39.0%) were HIV-infected. Of HIV-infected patients, the median CD4 cell count was 98 cells/µL (range, 1-1,105 cells/ µL), 20 (12.7%) were receiving ART, and 29 (18.5%) were receiving trimethoprim-sulfamethoxazole prophylaxis. There were 112 (27.7%) patients who had evidence of invasive disease, including 26 (23.2%) with Salmonella serotype Typhi infection, 24 (21.4%) with Streptococcus pneumoniae infection, 17 (15.2%) with Cryptococcus neoformans infection, 12 (10.7%) with Mycobacterium tuberculosis complex infection, 8 (7.1%) with Plasmodium falciparum infection, and 7 (6.3%) with Escherichia coli infection. HIV infection was associated with M. tuberculosis and C. neoformans bloodstream infection but not with E. coli, S. pneumoniae, or P. falciparum infection. HIV infection appeared to be protective against Salmonella. Typhi bloodstream infection (odds ratio, .12; P = .001). CONCLUSIONS: while Salmonella Typhi and S. pneumoniae were the most common causes of invasive infection overall, M. tuberculosis and C. neoformans were the leading causes of bloodstream infection among HIV-infected inpatients in Tanzania in the ART era. We demonstrate a protective effect of HIV against Salmonella. Typhi bloodstream infection in this setting. HIV co-infections continue to account for a large proportion of febrile admissions in Tanzania.

Invasive bacterial and fungal infections among hospitalized HIV-infected and HIV-uninfected children and infants in northern Tanzania.

OBJECTIVE: To describe the contribution of paediatric HIV and of HIV co-infections to admissions to a hospital in Moshi, Tanzania, using contemporary laboratory methods. METHODS: During 1 year, we enrolled consecutively admitted patients aged ≥2 months and <13 years with current or recent fever. All patients underwent standardized clinical history taking, a physical examination and HIV antibody testing; standard aerobic blood cultures and malaria film were also done, and hospital outcome was recorded. Early infant HIV diagnosis by HIV-1 RNA PCR was performed on those aged <18 months. HIV-infected patients also received serum cryptococcal antigen testing and had their CD4-positive T-lymphocyte count and percent determined. RESULTS: A total of 467 patients were enrolled whose median age was 2 years (range 2 months-13 years); Of those patients, 57.2% were female and 12.2% were HIV-infected. Admission clinical diagnosis of HIV disease was made in 10.7% and of malaria in 60.4%. Of blood cultures, 5.8% grew pathogens; of these 25.9% were Salmonella enterica (including 6 Salmonella Typhi) and 22.2%Streptococcus pneumoniae. Plasmodium falciparum was identified on blood film of 1.3%. HIV infection was associated with S. pneumoniae (odds ratio 25.7, 95% CI 2.8, 234.0) bloodstream infection (BSI), but there was no evidence of an association with Escherichia coli or P. falciparum; Salmonella Typhi BSI occurred only among HIV-uninfected participants. The sensitivity and specificity of an admission clinical diagnosis of malaria were 100% and 40.3%; and for an admission diagnosis of bloodstream infection, they were 9.1% and 86.4%, respectively. CONCLUSION: Streptococcus pneumoniae is a leading cause of bloodstream infection among paediatric admissions in Tanzania and is closely associated with HIV infection. Malaria was over-diagnosed clinically, whereas invasive bacterial disease was underestimated. HIV and HIV co-infections contribute to a substantial proportion of paediatric febrile admissions, underscoring the value of routine HIV testing.

Integrated Care Management to Improve Diabetes Outcomes in Refugee and Immigrant Patients (I-Care).

Purpose: Refugee and immigrant patients face significant barriers to health care and are more likely to have poorly controlled chronic disease than the general U.S. population. I-Care aims to improve health equity for refugees and immigrants who face a disproportionate burden of chronic disease. Methods: Refugees and immigrants with uncontrolled diabetes and associated cardiovascular risk factors were enrolled in a care management program within an academic adult medicine clinic. The program utilized a care manager to coordinate care and services between designated primary care providers, affiliated clinical teams, and community partners. Health literacy, chronic disease parameters, and care utilization were assessed at enrollment and 8-12 months later. Results: A total of 50 refugees and immigrants were followed for 8 to 12 months. Clinical parameters found a reduced mean HbA1c from 9.32 to 8.60 (p=0.05) and reduced low-density lipoprotein mean from 96.22 to 86.60 (p=0.01). The frequency of normal blood pressures was 9 (18%) at enrollment and 16 (32%) at 1 year. The cumulative frequency of emergency room visits decreased from 66% to 36% and hospitalizations from 22% to 8%. Rates of comprehensive care monitoring, including monofilament testing and one-time ophthalmology visits, increased from 60% to 82% and from 32% to 42%, respectively. Cumulative frequency of interdisciplinary support engagement with pharmacy and nutrition visits increased from 58% to 78% and from 26% to 38%, respectively. Conclusion: This program highlights the importance of a multidisciplinary community-engaged care model that has demonstrated improvement in quality metrics and health care costs for refugees and immigrants.

Managing adverse events associated with sorafenib in renal cell carcinoma.

Sorafenib, a multi-targeted kinase inhibitor, is approved in Europe for the treatment of patients with advanced renal cell carcinoma whose treatment with an interferon or interleukin-2-based therapy has previously failed, or who are unsuitable for such therapy. Unlike some first-generation anti-cancer therapies, sorafenib is generally associated with moderate and manageable adverse events. Some of the most common adverse events include a hand-foot skin reaction, diarrhoea and rash. As nurses provide an interface between the patient and the clinical team, it is important that they understand how sorafenib-related adverse events impact on patients. It is equally vital that nurses are able to recognize and manage these adverse events. Our experience has shown that with patient education, early reporting, monitoring and treatment, the adverse events of sorafenib therapy can be easily and effectively managed. Optimal adverse event management helps ensure treatment compliance and ensures that patients receive maximum benefit from therapy.

Lead Exposure in Newly Resettled Pediatric Refugees in Syracuse, NY.

Lead is a major environmental toxin that presents numerous health consequences for children. Refugee children are at a risk of lead poisoning post-resettlement due to urban housing and environmental inequalities stemming from lack of funding, legislation, and advocacy. This article addresses lead exposure upon arrival and post-resettlement in 705 refugee children (age 0-16 years) attending a university clinic in Syracuse, NY, a city with a large refugee population. 17% of the newly arrived children had elevated blood lead levels (BLLs) (≥ 5 µg/dL); 10% had elevated BLL upon follow-up; 8.3% of the children's follow-up elevated BLL were new exposures. 30% were found to have increased BLL at follow-up regardless of arrival status. An analysis of new exposures found a significant proportion of children would have been missed on routine screening that targets children < 2 years old. Primary prevention efforts are needed to prevent exposure and address risks to improve the health of all children locally, including newly resettled refugees.

The self-prescribed use of aromatherapy oils by pregnant women.

BACKGROUND: While some studies have reported effectiveness of aromatherapy oils use during labour there is no reported evidence of efficacy or risks of aromatherapy oils use for pregnancy-related symptoms or conditions. A number of aromatherapy oils are unsafe for use by pregnant women yet there is currently no research examining the prevalence and characteristics of women who use aromatherapy oils during pregnancy. AIM: To conduct an empirical study of the prevalence and characteristics of women who use aromatherapy oils during pregnancy. METHODS: The research was conducted as part of the Australian Longitudinal Study on Women's Health (ALSWH), focusing on the nationally representative sample of Australian women aged 31-36 years. Data were collected via a cross-sectional questionnaire (n=8200) conducted in 2009. RESULTS: Self-prescribed aromatherapy oils were used by 15.2% of pregnant women. Pregnant women were 1.57 (95% CI: 1.01, 2.43) times more likely to self-prescribe use of aromatherapy oils if they have allergies or hayfever, and 2.26 (95% CI: 1.34, 3.79) times more likely to self-prescribe use of aromatherapy oils if they have a urinary tract infection (UTI). CONCLUSION: Our study highlights a considerable use of aromatherapy oils by pregnant women. There is a clear need for greater communication between practitioners and patients regarding the use of aromatherapy oils during pregnancy, as well a need for health care practitioners to be mindful that pregnant women in their care may be using aromatherapy oils, some of which may be unsafe.

Stakeholder perceptions of job stress in an industrialized country: implications for policy and practice.

We used a secondary, qualitative analysis of stakeholder perceptions of work stress in Australia to characterize the context for policy and practice intervention. Themes included: Individual versus contextual descriptions of stress; perceived 'gender' differences in manifesting and reporting of stress; the work/home interface; and perceived sectoral and occupational differences in compensation claim rates. We found that people often still perceive stress as an individual rather than organizational problem and view work stress as a stereotypically feminine weakness that affects only certain people. Organizations downplay and overlook risks, increasing worker reluctance to report stressors, creating barriers to job stress interventions. Our study may be relevant to other industrial countries where researchers currently study job stress interventions to improve their effectiveness. Comprehensive approaches can increase knowledge and decrease stigma about job stress and mental illness, and target both work- and non-work-related influences on mental health.

Addressing the cultural complexity of OHS in the Australian mining industry.

This paper summarises the findings of the site assessments of ten pilot mine sites involved in a project entitled, Creating a world-leading OHS culture in the NSW Mining Industry which was undertaken for the New South Wales Mine Safety Advisory Council (NSW MSAC). NSW MSAC was established in 1998 in NSW Australia and aims to increase the emphasis on safety and health within the mining industry by reviewing and analyzing safety performance, setting strategic directions, providing advice and developing policy recommendations. The project itself aimed to deliver a self-sustaining method for achieving and monitoring continuous improvement in OHS culture and practice to the NSW mining industry. The pilot sites involved in the project tested a set of self-assessment tools to enable mines to assess and improve their own OHS culture and performance on key elements of an OHS management system. The tools allowed examination of the current OHS culture of the sites. Sites then used a participative planning process to develop an improvement plan. This paper provides summary data only, without identifying the individual sites that were the source of the data.