Global Health Training Collaborations: Lessons Learned and Best Practices.

Interest in global health training experiences among trainees from higher income countries has grown. The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) clarified best practices in 2010 based on expert consensus. These guidelines address both balancing priorities in international partnerships and local sustainability concerns related to short-term experiences. However, the guidelines can be difficult to implement in actual practice. Because our organization predated the availability of these consensus guidelines, we reviewed our current set of practices for hosting service-learning programs at our rural Ugandan clinic for adherence to the WEIGHT guidelines. The discrete activities and standardized processes developed over 10 years of hosting experiences were grouped into broader hosting categories, with consensus among the hosting and sending volunteer coordinators of our non-governmental organization partnership. These practices were then mapped to the WEIGHT guidelines. We found our implementation strategies map these guidelines into a clear checklist of actions that can be used by coordinators involved in global health training programs. We include some of the historical reasons that led to our current processes, which may help other partnerships identify similar practice gaps. We anticipate that this action-oriented checklist with historical context will help accomplish the difficult implementation of best practices in global health training collaborations.

Utilizing quantitative measures of visceral adiposity in evaluating trauma patient outcomes.

INTRODUCTION: Body mass index (BMI) has commonly been used as a parameter to assess obesity in trauma patients. However, the variability of height and weight data in trauma patients limits the use of BMI as an accurate assessment tool in the trauma population. Quantitative radiologic measurements of visceral adiposity is an accurate method for assessing obesity in patients but requires further analysis before it can be accepted as a measurement tool for trauma patients. METHODS: A retrospective review of trauma cases with pre-operative CT scan from 2008 to 2015 produced 57 patients for evaluation. Preoperative BMI was calculated using measured height (m2) and weight (kg). Radiologic measurements of adiposity were obtained from preoperative CT scans using OsiriX DICOM viewer software. Visceral fat areas (VFA) and subcutaneous fat areas (SFA) were measured from a single axial slice at the level of L4-L5 intervertebral space. RESULTS: No statistically significant results were found relating visceral fat:subcutaneous fat ratios to length of stay or post-operative complications. Initial clinical observations noting an increased incidence of complications among patients with a V/S ≥ 0.4 demonstrates a possible link between obesity and poor outcomes in trauma patients. A statistically significant correlation was noted between length of stay, peri-nephric fat and injury severity score. DISCUSSION AND CONCLUSION: Our pilot study should be viewed as the foundation for a larger prospective study, utilizing quantitative measurements of visceral adiposity to assess outcomes in trauma patients.

Congenital anomaly of the inferior vena cava and factor V Leiden mutation predisposing to deep vein thrombosis.

A previously healthy 21-year-old man presented with back pain, bilateral extremity pain, and right lower extremity weakness, paresthesias, and swelling. Sonographic examination revealed diffuse deep vein thrombosis (DVT) in the femoral and popliteal venous system. CT imaging revealed hypoplasia of the hepatic inferior vena cava (IVC) segment with formation of multiple varices and collateral veins around the kidneys. Hematologic workup also discovered a factor V Leiden mutation, further predisposing the patient to DVT. The rare, often overlooked occurrence of attenuated IVC, especially in the setting of hypercoagulable state, can predispose patients to significant thrombosis.

Brachial artery responses to ambient pollution, temperature, and humidity in people with type 2 diabetes: a repeated-measures study.

BACKGROUND: Extreme weather and air pollution are associated with increased cardiovascular risk in people with diabetes. OBJECTIVES: In a population with diabetes, we conducted a novel assessment of vascular brachial artery responses both to ambient pollution and to weather (temperature and water vapor pressure, a measure of humidity). METHODS: Sixty-four 49- to 85-year-old Boston residents with type 2 diabetes completed up to five study visits (279 repeated measures). Brachial artery diameter (BAD) was measured by ultrasound before and after brachial artery occlusion [i.e., flow-mediated dilation (FMD)] and before and after nitroglycerin-mediated dilation (NMD). Ambient concentrations of fine particulate mass (PM2.5), black carbon (BC), organic carbon (OC), elemental carbon, particle number, and sulfate were measured at our monitoring site; ambient concentrations of carbon monoxide, nitrogen dioxide, and ozone were obtained from state monitors. Particle exposure in the home and during each trip to the clinic (home/trip exposure) was measured continuously and as a 5-day integrated sample. We used linear models with fixed effects for participants, adjusting for date, season, temperature, and water vapor pressure on the day of each visit, to estimate associations between our outcomes and interquartile range increases in exposure. RESULTS: Baseline BAD was negatively associated with particle pollution, including home/trip-integrated BC (-0.02 mm; 95% CI: -0.04, -0.003, for a 0.28 µg/m3 increase in BC), OC (-0.08 mm; 95% CI: -0.14, -0.03, for a 1.61 µg/m3 increase) as well as PM2.5, 5-day average ambient PM2.5, and BC. BAD was positively associated with ambient temperature and water vapor pressure. However, exposures were not consistently associated with FMD or NMD. CONCLUSION: Brachial artery diameter, a predictor of cardiovascular risk, decreased in association with particle pollution and increased in association with ambient temperature in our study population of adults with type 2 diabetes. CITATION: Zanobetti A, Luttmann-Gibson H, Horton ES, Cohen A, Coull BA, Hoffmann B, Schwartz JD, Mittleman MA, Li Y, Stone PH, de Souza C, Lamparello B, Koutrakis P, Gold DR. 2014. Brachial artery responses to ambient pollution, temperature, and humidity in people with type 2 diabetes: a repeated-measures study. Environ Health Perspect 122:242-248; http://dx.doi.org/10.1289/ehp.1206136.

The association of circulating angiogenic factors and HbA1c with the risk of preeclampsia in women with preexisting diabetes.

OBJECTIVE: To assess whether glycemic control, soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF) were associated with the development of preeclampsia (PE) or gestational hypertension (GHTN) in women with preexisting diabetes. METHODS: Maternal circulating angiogenic factors (sFlt1 and PlGF) measured on automated platform were studied at four time points during pregnancy in women with diabetes (N = 159) and reported as multiples of the median (MOM) of sFlt1/PlGF ratio (median, 25th-75th percentile) noted in non-diabetic non-hypertensive control pregnant population (N = 139). Diagnosis of PE or GHTN was determined by review of de-identified clinical data. RESULTS: PE developed in 12% (N = 19) and GHTN developed in 23% (N = 37) of the women with diabetes. Among diabetic women without PE or GHTN, median sFlt1/PlGF levels at 35-40 weeks was threefold higher than in non-diabetic controls [MOM 3.21(1.19-7.24), p = 0.0001]. Diabetic women who subsequently developed PE had even greater alterations in sFlt1/PlGF ratio during the third trimester [MOM for PE at 27-34 weeks 15.18 (2.37-26.86), at 35-40 weeks 8.61(1.20-18.27), p ≤ 0.01 for both windows compared to non-diabetic controls]. Women with diabetes who subsequently developed GHTN also had significant alterations in angiogenic factors during third trimester; however, these findings were less striking. Among women with diabetes, glycosylated hemoglobin (HbA1c) during the first trimester was higher in subjects who subsequently developed PE (7.7 vs 6.7%, p = 0.0001 for diabetic PE vs diabetic non-PE). CONCLUSIONS: Women with diabetes had a markedly altered anti-angiogenic state late in pregnancy that was further exacerbated in subjects who developed PE. Altered angiogenic factors may be one mechanism for the increased risk of PE in this population. Increased HbA1c in the first trimester of pregnancies in women with diabetes was strongly associated with subsequent PE.

Face time: educating face transplant candidates.

OBJECTIVE: Face transplantation is the innovative application of microsurgery and immunology to restore appearance and function to those with severe facial disfigurements. Our group aims to establish a multidisciplinary education program that can facilitate informed consent and build a strong knowledge base in patients to enhance adherence to medication regimes, recovery, and quality of life. METHODS: We analyzed handbooks from our institution's solid organ transplant programs to identify topics applicable to face transplant patients. The team identified unique features of face transplantation that warrant comprehensive patient education. RESULTS: We created a 181-page handbook to provide subjects interested in pursuing transplantation with a written source of information on the process and team members and to address concerns they may have. While the handbook covers a wide range of topics, it is easy to understand and visually appealing. CONCLUSIONS: Face transplantation has many unique aspects that must be relayed to the patients pursuing this novel therapy. Since candidates lack third-party support groups and programs, the transplant team must provide an extensive educational component to enhance this complex process. PRACTICE IMPLICATIONS: As face transplantation continues to develop, programs must create sound education programs that address patients' needs and concerns to facilitate optimal care.

Vascularized composite allotransplantation and tissue engineering.

For many living with the devastating aftermath of disfiguring facial injuries, extremity amputations, and other composite tissues defects, conventional reconstruction offers limited relief. Full restoration of the face or extremities with anatomic equivalents recently became possible with decades of advancements in transplantation and regenerative medicine. Vascularized composite allotransplantation (VCA) is the transfer of anatomic equivalents from immunologically and aesthetically compatible donors to recipients with severe defects. The transplanted tissues are "composite" because they include multiple types essential for function, for example, skin, muscle, nerves, and blood vessels. More than 100 patients worldwide have benefited from VCA, the majority receiving hand or face transplants. Despite its demonstrated results, the clinical practice of VCA is limited by center experience, public awareness, donor shortage, and the risks of lifelong immune suppression. Tissue engineering (TE) is the generation of customized tissues in the laboratory using cells, biomaterials and bioreactors. Tissue engineering may eventually supersede VCA in the clinic, because it bypasses donor shortage and immune suppression challenges. Billions of dollars have been invested in TE research and development, which are expected to result in a myriad of clinical products within the mid- to long-term. First, tissue engineers must address challenges such as vascularization of engineered tissues and maintenance of phenotype in culture. If these hurdles can be overcome, it is to be hoped that the lessons learned through decades of research in both VCA and TE will act synergistically to generate off-the-shelf composite tissues that can thrive after implantation and in the absence of immune suppression.

Validation of a food frequency questionnaire for determining calcium and vitamin D intake by adolescent girls with anorexia nervosa.

Assessing calcium and vitamin D intake becomes important in conditions associated with low bone density such as anorexia nervosa. Food records that assess intake over a representative time period are used in research and sometimes clinical settings. However, compliance in adolescents can be suboptimal. This study was undertaken to determine the validity of a food frequency questionnaire (FFQ) for assessing calcium and vitamin D intake in adolescent girls with anorexia nervosa and healthy girls compared to validated food records assessing intake during a 4-day period, the hypothesis being that intake would be adequately predicted by the FFQ. Thirty-six girls with anorexia nervosa and 39 healthy girls aged 12 to 18 years completed both the food record and the FFQ. An additional 31 subjects (20 with anorexia nervosa, 11 controls) completed the FFQ, but not the food record, and one girl with anorexia nervosa completed the food record, but not the FFQ. Subjects demonstrated greater compliance with the FFQ (99%) than the food record (71%). Daily calcium and vitamin D intake calculated using the food record and FFQ did not differ, although the FFQ tended to under-report vitamin D intake corrected for energy intake. Using quartile analysis, no gross misclassification was noted of calcium or vitamin D intake calculated using the food record or FFQ in girls with anorexia nervosa. Strong correlations were observed for daily vitamin D intake derived from the FFQ vs the food record, particularly in girls with anorexia nervosa (r=0.78, P<0.0001). Less robust correlations were observed for calcium intake (r=0.65, P<0.0001). The FFQ used in this study can be effectively used to assess daily calcium and vitamin D intake in adolescent girls with anorexia nervosa.

Bone metabolism in adolescent athletes with amenorrhea, athletes with eumenorrhea, and control subjects.

OBJECTIVE: We hypothesized that, despite increased activity, bone density would be low in athletes with amenorrhea, compared with athletes with eumenorrhea and control subjects, because of associated hypogonadism and would be associated with a decrease in bone formation and increases in bone-resorption markers. METHODS: In a cross-sectional study, we examined bone-density measures (spine, hip, and whole body) and body composition by using dual-energy radiograph absorptiometry and assessed fasting levels of insulin-like growth factor I and bone-turnover markers (N-terminal propeptied of type 1 procollagen and N-telopeptide) in 21 athletes with amenorrhea, 18 athletes with eumenorrhea, and 18 control subjects. Subjects were 12 to 18 years of age and of comparable chronologic and bone age. RESULTS: Athletes with amenorrhea had lower bone-density z scores at the spine and whole body, compared with athletes with eumenorrhea and control subjects, and lower hip z scores, compared with athletes with eumenorrhea. Lean mass did not differ between groups. However, athletes with amenorrhea had lower BMI z scores than did athletes with eumenorrhea and lower insulin-like growth factor I levels than did control subjects. Levels of both markers of bone turnover were lower in athletes with amenorrhea than in control subjects. BMI z scores, lean mass, insulin-like growth factor I levels, and diagnostic category were important independent predictors of bone mineral density z scores. CONCLUSIONS: Although they showed no significant differences in lean mass, compared with athletes with eumenorrhea and control subjects, athletes with amenorrhea had lower bone density at the spine and whole body. Insulin-like growth factor I levels, body-composition parameters, and menstrual status were important predictors of bone density. Follow-up studies are necessary to determine whether amenorrhea in athletes adversely affects the rate of bone mass accrual and therefore peak bone mass.