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Poster Session Submissions

The Global Health Education Day virtual poster session was held on May, 13th, 2020. All posters will be remain publicly available, and you are welcome to view the virtual poster submissions below.


 A Case of JC Virus Granule Cell Neuronopathy in an HIV+ Patient Presenting with Severe Ataxia
Adrissi, Jennifer - 2020 (Honorable Mention - Clinical Oral Poster Presentation)

Background: JC Virus granule cell neuronopathy (JCV GCN) is a lytic infection of granule cells in the cerebellum caused by reactivation of JC Virus (JCV) in immunocompromised hosts. JCV is a polyomavirus that is also the causative agent for progressive multifocal leukoencephalopathy (PML), a demyelinating disorder also on the differential for abnormal brain lesions in the immunocompromised. Unlike PML, JCV GCN is contained to the cerebellum and spares the white matter. There are 1.2 million people living with HIV in Zambia including 16% of adults aged 15 -59 in its capital, Lusaka. JCV GCN can be the first manifestation of AIDS in this population and is likely under-diagnosed due to limitations in healthcare access including available neurologists and necessary lab and imaging capabilities. 

Case Report: We present the case of a 42-year-old male with a past medical history of HIV on highly active antiretroviral therapy (HAART) admitted with one year of progressive neurologic decline. He presented with progressive gait instability, incoordination, slurred speech, and difficulty swallowing. By the time of hospital presentation, he was unable to walk, and his speech was unintelligible due to severe dysarthria. His exam was notable for severe ocular and appendicular dysmetria, truncal ataxia, and dysarthria. Laboratory analysis was most notable for a CD4 count of 218 cells/mm3, and cerebrospinal fluid (CSF) analysis was unremarkable. JCV testing was not available. Brain CT was notable for significant bilateral cerebellar atrophy with relative preservation of white matter leading to the probable diagnosis of JCV GCN based on clinical presentation and imaging findings. 

Lessons Learned: With both PML and JCV GCN on the differential for the patient discussed, it was important to advocate for imaging to further the diagnostic workup for this patient. While unable to obtain a JCV PCR, we are able to make a probable diagnosis of JCV GCN based on clinical presentation and imaging. In an immunocompromised patient presenting with progressive ataxia, incoordination, and dysarthria, there should be a low threshold to consider JCV-associated diseases such as JCV GCN. 

 Role of POCUS in Pulmonary Hypertension
Anugerah, Ariana - 2020

Introduction: Pulmonary hypertension (PH) is a progressive disease characterized by remodeling of the pulmonary vasculature which can lead to right heart failure and eventual death. Although data suggests a high prevalence of PH in Sub-Saharan Africa, less than 1% of publications on PH are from Africa [1]. These patients tend to present to healthcare late, resulting in delayed diagnosis, worse outcomes and a higher mortality rate [2]. 

Right heart catheterization (RHC) is the gold standard for PH diagnosis but is expensive and not readily available in low- resource settings. Transthoracic echocardiography (TTE) is an effective screening tool for PH and is the most common diagnostic modality in Africa [3,4]. The goal of this review is to examine current literature on the epidemiology, diagnosis and role of cardiac ultrasound in PH in Africa. 

Methods: The literature review was conducted by searching Google Scholar and PubMed for "pulmonary hypertension," "ultrasound," and "Africa" from February 2010 to February 2020. The abstracts and selected references were screened for relevant content and six publications were included for the review. 

Results: In 2016, the Pan African Pulmonary Hypertension Cohort reported that the majority of patients with PH had poor functional status and a high 6-month mortality rate (21%). A 2018 study showed similar findings of late clinical presentation with a 30% 6-month mortality rate. Late presentation was attributed to misdiagnosis, poor access to healthcare, financial constraints, limited availability of diagnostic tools, treatment limitations and reluctance of patience to seek medical attention until later stages of the disease [6]. A 2019 study found that nearly 39% of patients with heart failure were found to have PH and were found to have worse functional impairment and worse biventricular function, higher left ventricular filling pressures and severe mitral regurgitation [3]. 

The gold standard for diagnosis of PH is RHC but in Africa and other low-resource settings, this is not a viable option. RHC is expensive and invasive with risk of complications [7]. Transthoracic echocardiography (TTE) is the primary diagnostic method for PH in Africa, with a reported high sensitivity (83%) and moderate sensitivity (72%) although there are limitations [7]. While RHC directly measures pulmonary pressures, TTE can only estimate PASP by adding RVSP to RAP. However this requires the presence of sufficient tricuspid regurgitation jet. 

To reduce delays in diagnosis of PH, use of TTE for screening for PH has been recommended for risk stratification [3]. Diagnostic algorithms have been proposed to implement this in resource-limited settings [9,10]. Increasingly non-cardiologists are performing point-of-care focused cardiac ultrasound with comparable results to cardiologists [4]. POCUS has been shown to have utility in the emergency and critical care settings where it influences diagnosis and therapy in 84% and 69% of cases [11]. 

Conclusion: Diagnosis and management of pulmonary hypertension in Africa is challenging. Increasing the availability of POCUS in low- resource settings for screening of PH may lead to quicker diagnosis and improved outcomes. More high quality studies will be needed to determine the efficacy of POCUS in screening for pulmonary hypertension.

 Asylum Clinics: Establishing a Legal, Medical, and Ethical Framework for the Global Healthcare Practitioner's Role
Campbell, Charlotte - 2020 (Best Poster Winner - Program or Project Oral Poster Presentation)

Academic medical centers with large footholds in the sphere of global health should also determine and engage the needs of global-local communities. One example of this is seen in the emergence of asylum clinics for local refugees. Much is demanded of refugees in the completion of an asylum application and in the judicial wait time. Groups such as Physicians for Human Rights partner with clinician volunteers to aid these vulnerable groups of people and encourage the formation of medical student-run asylum clinics. Medical professionals and students volunteer time with asylum clinics to help clients complete a medical affidavit as part of application for asylum. Past models for clinics have shown that assistance with a
medical-legal affidavit can increase likelihood of receiving asylum status from less than 38% to almost 90% [1, 2]. With such successes, it is unfortunate that there still exists a deficit of available clinics to conduct examinations as well as trained physicians to volunteer spare time to staff them. Increased teaching of the legal process as well as proper training in forensic examinations required for medical affidavits would help improve outreach, especially in academic centers that place strong emphasis on values for global health. Reexamining the ethical principles guiding involvement in such efforts may also encourage continued growth in the aid and delivery of justice for undeserved asylee populations.

1. Lustig, S.L., et al., Asylum Grant Rates Following Medical Evaluations of Maltreatment among Political Asylum Applicants in the United States. Journal of Immigrant and Minority Health, 2008. 10(1): p. 7-15.
2. Praschan, N., R. Mishori, and N. Stukel, A Student-Run Asylum Clinic to Promote Human Rights Education and the Assessment and Care of Asylum Seekers. Journal of Student-Run Clinics, 2016. 2(2).

 I-PACK (Immigrant Partnerships and Advocacy Curricular Kit) Education Modules: Advocacy in Action
Chun, Angela - 2020

Immigrant, asylee, and refugee health is of growing interest to clinicians, educators, and trainees, yet it is challenging for busy educators to develop and implement curricula to equip trainees to positively interact with this community. To address this need, members of the Midwest Consortium of Global Child Health Educators developed I-PACK (Immigrant Partnerships and Advocacy Curricular Kit), a modular and modifiable curriculum addressing five domains of immigrant health:

  1. Practical Clinical Concerns
  2. Medicolegal Considerations
  3. Community-Focused Initiatives
  4. Structured Educational Programs for Trainees
  5. Advocacy in Action

Originally planned to go-live at the 2020 Pediatric Academics Societies meeting, the target audience for these workshops include program directors and associate program directors, advocacy track leaders, faculty or trainees interested in advocacy, educators and providers interested in community partnerships with immigrant families. This Advocacy in Action module follows one family's story and provides examples of advocacy at multiple levels, ranging from advocating for an individual patient in your clinic to advocating for a vulnerable population at the state and federal level. The module includes three interactive advocacy activities: interpreter best practices, policy stakeholder mapping, and letter writing to your representative. Learning objectives are as follows:

  1. Identify opportunities for advocacy for immigrant and refugee families at multiple levels including for individual patients, in your community, and at the state and federal level
  2. Define interpreter best practices and implement them in your practice
  3. Create a policy stakeholder map to address an issue in your community
  4. Develop advocacy writing skills in several areas including social media, news media, and letter writing to elected representatives. Participants will see each of these objectives in action as part of the interactive workshop and will identify ways to implement this activity at their home institution.

 First Steps for NU Medical Education Partnership Initiative: Pediatric Emergencies Simulation-Based Education at Maseno University in Kisumu, Kenya
Ekeh, Odera - 2020

Background: Pediatric Emergency Medicine (EM) as a medical specialty does not exist in many parts of the world. In low- and middle- income countries (LMICs), the majority of care for acutely ill children is done by providers with limited emergency medicine or dedicated pediatric training. Simulation-based education is a widely recognized tool to teach medically challenging and emergent scenarios allowing participants to gain experience and preparation in a supervised environment without compromising patient safety. The Northwestern University Medical Education Partnership Initiative (NU-MEPI) project aims to implement a partnership in medical education with the goal of strengthening educational systems. The inaugural project is with Maseno University in collaboration with Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) to build an emergency medicine pediatric simulation training program. Adapting the Kern (2016) curricular development methodology as a basis, we have completed the first two of six steps of curriculum development and here we present these results. The next steps will be to develop, infrastructure, and partnerships to support the academic ecosystem in Kenya for teaching medicine and identifying educational best practices. This first project under the NU-MEPI umbrella is a pilot to develop a longitudinal
bilateral international educational partnership, workforce and faculty development, education research, and interdisciplinary healthcare approaches.

Methods: Step 1 and 2 of the Kern Model (1) problem identification and general needs assessment and (2) targeted needs assessment) were completed with local and key stakeholders at Maseno University and JOORTH. Topics, contents, and curriculum were developed and we conducted several asset-based needs assessments with key stakeholders to agree upon step 3 of the model, the development of goals and objectives of the curriculum as well as the overall partnership. We are now working on Step 4, developing educational strategies.

Stakeholder meetings occurred with key informants at multiple institutional levels across both Maseno and JOOTRH. Key activities identified were: Maseno/JOOTRH faculty and trainee clinical, research, and education development. Key assets and opportunities identified were: leveraging the Center for Experiential Learning Simulation at JOORTH; focusing on education that drives improved clinical outcomes, and engaging with interprofessional and team collaboration around communication.

Our targeted assessment identified the need for further pediatric specialty training, simulation, and case-based learning were determined, target learners identified as 6th-year medical students, specific content areas of simulation cases as well as a diverse set of additional research and education activities that our partners wanted to explore further.

The NU-MEPI program completed the first two steps of the Kern model for curriculum development. Next steps are to translate these assessments to clear learning goals and objectives, agree upon educational strategies and then strategy implementation.

Kern, D. E. (2016). A six-step approach to curriculum development. P. Thomas, D. Kern, M., Hughes, & B. Chen, Curriculum development for medical education, 5-9.

 Development of a Simulation of Neonatal Respiratory Distress Syndrome for a Resource Limited Setting
Feister, John - 2020

Background: Prematurity-related complications are the leading cause of neonatal mortality worldwide1. The incidence of preterm birth (PTB) is estimated to be 12% in sub-Saharan Africa2 and as high as 16% in Tanzania3. A major contributor of neonatal mortality due to preterm birth is respiratory distress syndrome (RDS). Bugando Medical Center (BMC) is a tertiary referral center for the northwest region of Tanzania. Premature newborns born at local or regional centers are frequently transferred to BMC for specialty management. BMC has access to a limited number of ventilators, bubble CPAP, and surfactant.

Objectives: We sought to create a simulation to teach the identification and initial stabilization of an outborn baby with RDS using the resources available to providers at BMC.

Methods: An informal needs assessment was done in partnership with the medical staff of BMC to understand which simulation scenarios were most relevant to the learners, as well as which scenarios were most desired by the pediatric educators at BMC. After discussion, the need for a neonatal RDS simulation emerged. The BMC NICU was observed to understand the available resources and current practices. To maintain consistency amongst simulation cases being developed, a common template was used. The simulation was designed using recommendations from the European Consensus Guidelines for
Management of RDS and the WHO Pocket Book of Hospital Care for Children.

A simulation guide was created for use at BMC, designed to teach medical students and pediatric residents how to identify respiratory distress in a neonate, as well as how to provide the initial steps in management for RDS. The complete simulation guide includes the simulation itself, as well as a structured debriefing guide and discrete learning points that should be addressed. The simulation guide is attached as Addendum A.

Discussion/Future Directions:
This simulation provides a novel learning experience for Tanzanian medical students and pediatric residents within the context of Bugando Medical Center. Strengths of this study include that it was designed specifically to fit within the context of BMC and the simulation can be conducted with low fidelity equipment. It has several limitations. First, it was created remotely without in-person feedback due travel imitations related to COVID-19. Use of virtual discussion and/or future in person implementation with feedback is anticipated. Secondly, the European Consensus guidelines are not designed for resource
limited settings. From our review of the literature, no standardized guidelines for treatment of RDS in resource limited settings exists. Future directions will include revision of the simulation with in-country physicians to tailor the simulation to BMC, procurement of enhanced simulation materials, such as neonatal mannequins who can be intubated, and implementation of the simulation with testing to assess knowledge and skill acquisition, as well as the impact on RDS outcomes for neonates at Bugando.

 Influences of an Interdisciplinary Global Health Program on Cultural Awareness and Future Global Health Involvement: A Pilot Study
Frisby-Zedan, Jeanne - 2020

Background: Over the past few decades, graduate medical trainees have become increasingly involved in global health. There is evolving evidence that involvement of medical students and resident physicians in global health activities influences their future involvement in global health work or work with immigrant populations as attending physicians. To date, there has not been literature evaluating the influence of participation in an interdisciplinary global health program, such as that at McGaw Medical Center of Northwestern University. McGaw's Global Health Clinical Scholars (GHCS) program enrolls residents from many specialties, and provides them with medical and ethical simulation sessions and lectures on a variety of global health topics. Participants also complete a scholarly project and participate in a one-month global health elective. It is our hypothesis that this multidisciplinary approach to global health education within residency training improves overall self-reported cultural awareness and is a predictor of global health involvement in future career choices.

Methods: In this pilot study, we disseminated an anonymous electronic questionnaire to physicians who graduated between 2013-2019 from the Ann & Robert H. Lurie Children's Hospital of Chicago/McGaw Northwestern Pediatric Residency program. We compared GHCS program graduates with non-participants by analyzing demographic data, Likert Scales of Agreement, and data regarding current involvement in global health work or work with vulnerable immigrant/refugee populations. Results were analyzed using t-test and chi-square analysis. We also surveyed graduates of the certificate program regarding
satisfaction with the program and important lessons learned through participation in the program.

GHCS program graduates were more likely to have a good understanding of the impact that they would have as a visiting physician in another country and the impact that being a visiting physician would have on them, which they attributed to participation in the certificate program. There was no difference between the groups' feelings of preparedness for obstacles encountered in a culture different from their own, though certificate graduates felt that the program helped them to prepare for these obstacles. There was also no difference in the percentage of current or ideal participation in global health activities or work with immigrant/refugee populations as attending physicians, although both groups had higher percentages of ideal involvement in global health compared to their current percentage of involvement. Barriers to ideal involvement included time restraints, salary support from institutions, family commitments, and concerns about safety. GHCS graduates felt that the program helped them to better understand global health within a broader context and to understand what an appropriate scope of practice would be in a foreign country. Participants agreed that they would recommend a multidisciplinary global health program to future trainees as a stepping-stone to a global health career.

This study highlights the influence of an interdisciplinary global health program on cultural and self-awareness within the global health sphere and emphasizes the need for employers to provide institutional structure and support in order for attending physicians to participate in global health activities. Future studies will include expansion of the survey to graduates from other McGaw Northwestern residency programs.

 Prevalence of Prostate Cancer at Autopsy in Nigeria – Preliminary Results
Nettey, Rotimi - 2020

Funding: Catalyzer Grant from Institute for Global Health, Northwestern University, Chicago, IL, USA

Background and Objectives: Prostate cancer (PCa) is the most commonly diagnosed cancer in men worldwide and the most common cancer in Nigerian men despite the lack of PSA based screening. Current prevalence estimates in Nigeria are based on cancer registry data, obtained primarily from hospital admissions and thereby not truly reflective of cancer incidence. Prior autopsy series did not adhere to modern pathologic quality practices. We aim to establish the prevalence of asymptomatic PCa among Nigerian men undergoing high-quality forensic autopsy.

Methods:  Prostates are collected at autopsy at the Universities of Lagos and Calabar from men aged >40 who died from causes other than prostate cancer. Thirty-nine prostates from consecutively autopsied Nigerian men from 2018 to 2019 were formalin fixed, weighed, and step sectioned at 4 mm intervals. Hematoxylin and eosin stained paraffin sections were prepared from these slices. Gleason grade of  prostatic adenocarcinomas and presence of high-grade prostatic intraepithelial neoplasia (HGPIN) were recorded.

Results: Mean age of men who died of causes other than PCa was 54.6±11.1 years and mean prostatic weight was 25.8±11.1 grams. The prevalence of HGPIN was 12.8% and atypical small acinar proliferation was 5.6%. Overall prevalence of prostate cancer was 10.3%, increasing from 7.1% for men aged 40-59 (n=28) to 18.2% for men ­­­≥60 years old (n=11). The tumors were small and predominantly Gleason grade 3+3 or 3+4, with the exception of one large stage T3 tumor with Gleason grade 4+5 disease found in a 54 year-old man.

Conclusions: The prevalence of sub-clinical PCa at atutopsy (10.3%) was similar to previously reported Nigerian studies with more limited tissue sampling, but considerably lower than estimates in other vulnerable populations, including African Americans (prevalence rates up to 49%). Our findings suggest that latent, clinically asymptomatic PCa is less frequent in Nigerians than in African Americans despite shared genetic ancestry. Future studies with increased sample size are warranted to provide insight in the natural history and true prevalence of prostate cancer in West Africa.

 Enhancing Community Health Education Through Technology in Lagos, Nigeria
Tarzikhan, Alexandra - 2020 (Honorable Mention - Program or Project Oral Poster Presentation)

The Northwestern Access to Health Project (ATH) is an interdisciplinary global community health project that brings law, public health, medical, and business faculty and graduate students together with communities, health advocates, government and university institutions, and human rights organizations in other countries. ATH operates as part of the Center for International Human Rights at the Northwestern Pritzker School of Law and the Institute for Global Health at the Feinberg School of Medicine. Founded in 2011 by Professor Juliet Sorensen and Dr. Shannon Galvin, ATH encourages Northwestern graduate students to engage in global health issues by working directly with communities and local NGOs. By working across disciplines, ATH aims to create targeted and sustainable projects that respond to health-related issues of poor communities, and to teach students how to engage in interdisciplinary, transnational partnerships that encourage global citizenship and understanding.

The community health education (CHE) project and accompaniment program in Nigeria works with the Justice & Empowerment Initiative Nigeria (JEI), a civil society organization working in Nigerian urban informal settlements, and the Nigerian Slum / Informal Settlement Federation (Federation), an organization made up of members of community-level savings groups in slums and informal settlements in Lagos, Port Harcourt, and other Nigerian cities. The Federation collects community-generated data to feed into advocacy around informal settlement communities' collective priorities, including land tenure and access to basic services such as electricity, potable water, elementary education and health. While supporting
other Federation activities, JEI helps equip the urban poor with the knowledge and skills they need for meaningful civic participation. The Access to Health partnership with JEI has centered on community health education and accompaniment. The topics for the curriculum were chosen based on an initial needs assessment and include basic information on anatomy, water and sanitation, safe pregnancy, family planning, malaria, HIV, STDs, other commons infections, and vaccines. In order to expand the reach of the project and improve on the community health education program, ATH partnered with Slalom LLC
to design a website and mobile application solution, which would increase access to health information and transparency to services. The website provides updated, visual training materials to the CHEs through a scalable, user-friendly medium. Slalom also developed a mobile platform, allowing a full public health curriculum to reach even the most remote populations.

 Improving Pediatric Access to Ultrasound in a Tertiary Care Hospital in Malawi
Weber, Jonathon - 2020 (Best Poster Winner - Clinical Oral Poster Presentation)

Malawi ranks 185/190 in the WHO report of health systems development. It also has one of the highest rates of HIV/AIDS in the world. In addition to being a low-middle income country with poor infrastructure, these various factors create myriad issues for the delivery of quality care to patient in need.

Kamuzu Central Hospital is a state-funded tertiary care hospital in the largest city of Malawi, Lilongwe. Holding approximately 600-1,000 beds, the hospital is almost always above capacity. An estimated 70% of admissions are related to infectious disease/HIV-related illness. In addition, the hospital serves numerous specialties including pediatrics, oncology, obstetrics, surgery, and general medicine.

A pediatric death audit study at KCH reviewing data from 2014-15 demonstrated that 14.6% of patients whose deaths were reviewed had delays of greater than 24 hours in obtaining radiology studies. This was determined to be due to a multitude of reasons including access to equipment and lack of radiology specialists. RAD-AID, a nonprofit centered around delivery of radiology services to LMIC health systems, partnered with KCH in 2019. Goals of RAD-AID include improving technical skill and curriculum of local sonographers and improving patient (specifically pediatric) access to ultrasound exams. A cohort of
local learners was identified to provide longitudinal mentorship to adapt and manage the needs of the local healthcare environment. We want to ensure the sustainability of intervention by training and qualifying learners to have the ability to train future technologists.

RAD-AID sent the first cohort of American-trained technologists and physicians to provide hands-on teaching and real-time feedback for local sonographers in the fall of 2019. Interventions of RAD-AID volunteers included real-time feedback to learners, objective measurement of progress by filling out evaluation forms, and designing didactic lectures relevant to local healthcare needs. A local sonographer was funded to receive a master's degree in sonography. This is also a pilot site for a certificate-bearing ultrasound curriculum designed by Point of Care Ultrasound Academy and RAD-AID.

Early results are promising with improvement from evaluation forms, three local learners obtaining POCUS certificates, and funding of further degrees of local learners. Longer-term data collection is ongoing regarding these interventions on a hospital-wide basis.

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