Cultural and Linguistic Adaptations of Stop the Bleed in Multi-Ethnic Refugee Communities.

INTRODUCTION: Stop the Bleed (STB), and other trainings that promote health education in basic trauma management techniques, is offered mostly in English and Spanish in the United States. Limited access to injury prevention training may contribute to inequities in health outcomes for individuals with limited English proficiency (LEP). Our study aims to determine the feasibility and effectiveness of STB training in 4 languages spoken in a super diverse refugee settlement community, Clarkston, GA. METHODS: Written STB educational materials were culturally adapted, translated, and back translated into 4 languages: Arabic, Burmese, Somali, and Swahili. Four 90-minute in-person STB trainings were conducted by medical personnel with community-based interpreters at a central and familiar location in the Clarkston community. Pre- and post-tests were administered in participant's preferred language to evaluate change in knowledge and beliefs as well as the effectiveness of the training method. RESULTS: A total of 46 community members were trained in STB, the majority of which were women (63%). Participants demonstrated improvement in their knowledge, confidence, and comfort using STB techniques. Participants reported that 2 aspects of the training were particularly beneficial: the presence of language concordant interpreters from the community and small group hands on sessions that allowed for practicing STB techniques. CONCLUSION: Cultural and linguistic adaptation of STB training is a feasible, cost-effective, and effective method for disseminating life-saving information and trauma education to immigrant populations who have LEP. Expansion of community training and partnerships to support the needs of diverse communities is both necessary and urgent.

Emergency Medicine Around the World: Analysis of the 2019 American College of Emergency Physicians International Ambassador Country Reports.

OBJECTIVE: The specialty of emergency medicine and recognition of the need for emergency care continue to grow globally. The specialty and emergency care systems vary according to context. This study characterizes the specialty of emergency medicine around the world, trends according to region and income level, and challenges for the specialty. METHODS: We distributed a 56-question electronic survey to all members of the American College of Emergency Physicians International Ambassador Program between March 2019 and January 2020. The Ambassador Program leadership designed the survey covering specialty recognition, workforce, system components, and emergency medicine training. We analyzed results by country and in aggregate using SAS software (SAS Institute Inc). We tested the associations between World Bank income group and number of emergency medicine residency-trained physicians (RTPs) and emergency medicine specialty recognition using non-parametric Fisher's exact testing. We performed inductive coding of qualitative data for themes. RESULTS: Sixty-three out of 78 countries' teams (80%) responded to the survey. Response countries represented roughly 67% of the world's population and included countries in all World Bank income groups. Fifty-four countries (86%) recognized emergency medicine as a specialty. Ten (16%) had no emergency medicine residency programs, and 19 (30%) had only one. Eight (11%) reported having no emergency medicine RTPs and 30 (48%) had <100. Fifty-seven (90%) had an emergency medical services (EMS) system, and 52 (83%) had an emergency access number. Higher country income was associated with a higher number of emergency medicine RTPs per capita (P = 0.02). Only 6 countries (8%) had >5 emergency medicine RTPs per 100,000 population, all high income. All 5 low-income countries in the sample had <2 emergency medicine RTPs per 100,000 population. Challenges in emergency medicine development included lack of resources (38%), burnout and poor working conditions (31%), and low salaries (23%). CONCLUSIONS: Most surveyed countries recognized emergency medicine as a specialty. However, numbers of emergency medicine RTPs were small, particularly in lower income countries. Most surveyed countries reported an EMS system and emergency access number. Lack of resources, burnout, and poor pay were major threats to emergency medicine growth.

Characterization of Near Full-Length Transmitted/Founder HIV-1 Subtype D and A/D Recombinant Genomes in a Heterosexual Ugandan Population (2006-2011).

Detailed characterization of transmitted HIV-1 variants in Uganda is fundamentally important to inform vaccine design, yet studies on the transmitted full-length strains of subtype D viruses are limited. Here, we amplified single genomes and characterized viruses, some of which were previously classified as subtype D by sub-genomic pol sequencing that were transmitted in Uganda between December 2006 to June 2011. Analysis of 5' and 3' half genome sequences showed 73% (19/26) of infections involved single virus transmissions, whereas 27% (7/26) of infections involved multiple variant transmissions based on predictions of a model of random virus evolution. Subtype analysis of inferred transmitted/founder viruses showed a high transmission rate of inter-subtype recombinants (69%, 20/29) involving mainly A1/D, while pure subtype D variants accounted for one-third of infections (31%, 9/29). Recombination patterns included a predominance of subtype D in the gag/pol region and a highly recombinogenic envelope gene. The signal peptide-C1 region and gp41 transmembrane domain (Tat2/Rev2 flanking region) were hotspots for A1/D recombination events. Analysis of a panel of 14 transmitted/founder molecular clones showed no difference in replication capacity between subtype D viruses (n = 3) and inter-subtype mosaic recombinants (n = 11). However, individuals infected with high replication capacity viruses had a faster CD4 T cell loss. The high transmission rate of unique inter-subtype recombinants is striking and emphasizes the extraordinary challenge for vaccine design and, in particular, for the highly variable and recombinogenic envelope gene, which is targeted by rational designs aimed to elicit broadly neutralizing antibodies.

HIV-1 Gag-Pol Sequences from Ugandan Early Infections Reveal Sequence Variants Associated with Elevated Replication Capacity.

The ability to efficiently establish a new infection is a critical property for human immunodeficiency virus type 1 (HIV-1). Although the envelope protein of the virus plays an essential role in receptor binding and internalization of the infecting virus, the structural proteins, the polymerase and the assembly of new virions may also play a role in establishing and spreading viral infection in a new host. We examined Ugandan viruses from newly infected patients and focused on the contribution of the Gag-Pol genes to replication capacity. A panel of Gag-Pol sequences generated using single genome amplification from incident HIV-1 infections were cloned into a common HIV-1 NL4.3 pol/env backbone and the influence of Gag-Pol changes on replication capacity was monitored. Using a novel protein domain approach, we then documented diversity in the functional protein domains across the Gag-Pol region and identified differences in the Gag-p6 domain that were frequently associated with higher in vitro replication.

Building a virtual community of practice for medical students: The Global Emergency Medicine Student Leadership Program.

Virtual communities of practice (VCoPs) facilitate distance learning and mentorship by engaging members around shared knowledge and experiences related to a central interest. The American College of Emergency Physicians and Emergency Medicine Residents' Association's Global Emergency Medicine Student Leadership Program (GEM-SLP) provides a valuable model for building a VCoP for GEM and other niche areas of interest. This VCoP facilitates opportunities for experts and mentees affiliated with these national organizations to convene regularly despite barriers attributed to physical distance. The GEM-SLP VCoP is built around multiple forms of mentorship, monthly mentee-driven didactics, academic projects, and continued engagement of program graduates in VCoP leadership. GEM-SLP fosters relationships through (1) themed mentoring calls (career paths, work/life balance, etc); (2) functional mentorship through didactics and academic projects; and (3) near-peer mentoring, provided by mentors near the mentees' stage of education and experience. Monthly mentee-driven didactics focus on introducing essential GEM principles while (1) critically analyzing literature based on a journal article; (2) building a core knowledge base from a foundational textbook; (3) applying knowledge and research to a project proposal; and (4) gaining exposure to training and career opportunities via mentor career presentations. Group academic projects provide a true GEM apprenticeship as mentees and mentors work collaboratively. GEM-SLP mentees found the VCoP beneficial in building fundamental GEM skills and knowledge and forming relationships with mentors and like-minded peers. GEM-SLP provides a framework for developing mentorship programs and VCoPs in emergency medicine, especially when niche interests or geographic distance necessitate a virtual format.

Neurological Disorders Associated with Glutamic Acid Decarboxylase Antibodies.

Anti-glutamic acid decarboxylase (GAD) antibodies have been discovered in a variety of neurological syndromes with unique presentations. These syndromes include limbic encephalitis (LE), stiff person syndrome (SPS), opsoclonus-myoclonus-ataxia syndrome, cerebellar ataxia, status epilepticus, and palatal myoclonus among others. We present two patients who presented with Guillain-Barré (GBS) and myasthenia gravis (MG) like syndromes, who were found to have anti-GAD antibodies. These case reports highlight the complex presentation of patients with neurological disorders associated with anti-GAD antibodies. The proper identification of anti-GAD antibody's presence has proven to be beneficial in treatment and provide enhanced quality of life.

A Rare Case of Low-grade Appendiceal Mucinous Neoplasm: A Case Report.

Low-grade appendiceal mucinous neoplasm (LAMN) is a rare malignancy with symptoms varying depending on the clinical manifestations. The most worrisome complication of this particular neoplasm is seeding of mucin into the adjacent peritoneum leading to pseudomyxoma peritonei (PMP). There is a lack of standardized treatment approach; however, an appendectomy-only approach is currently being used for the resection of non-metastatic disease. We present an unusual case of a 67-year-old male found to have LAMN status post elective appendectomy, six months after being treated for an appendiceal abscess.