Nathan S. Bertelsen

The Role of Plasma Triglyceride/High‐Density Lipoprotein Cholesterol Ratio to Predict New Cardiovascular Events in Essential Hypertensive Patients

Triglyceride (TG) to high‐density lipoprotein cholesterol (HDL‐C) ratio (TG/HDL‐C) has been suggested as a simple method to identify unfavorable cardiovascular outcomes in the general population. The effect of the TG/HDL‐C ratio on essential hypertensive patients is unclear. About 900 consecutive essential hypertensive patients (mean age 52.9±12.6 years, 54.2% male) who visited our outpatient hypertension clinic were analyzed. Participants were divided into quartiles based on baseline TG/HDL‐C ratio and medical records were obtained periodically for the occurrence of fatal events and composite major adverse cardiovascular events (MACEs) including transient ischemic attack, stroke, aortic dissection, acute coronary syndrome, and death. Participants were followed for a median of 40 months (interquartile range, 35–44 months). Overall, a higher quartile of TG/HDL‐C ratio at baseline was significantly linked with higher incidence of fatal and nonfatal cardiovascular events. Using multivariate Cox regression analysis, plasma TG/HDL‐C ratio was independently associated with increased risk of fatal events (hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.13–1.37; P≤.001] and MACEs (HR, 1.13; 95% CI, 1.06–1.21; P≤.001). Increased plasma TG/HDL‐C ratio was associated with more fatal events and MACEs in essential hypertensive patients.

Clinical value of ambulatory blood pressure: Is it time to recommend for all patients with hypertension?

Hypertension is a very common disease, and office measurements of blood pressure are frequently inaccurate. Ambulatory Blood Pressure Monitoring (ABPM) offers a more accurate diagnosis, more detailed readings of average blood pressures, better blood pressure measurement during sleep, fewer false positives by detecting more white-coat hypertension, and fewer false negatives by detecting more masked hypertension. ABPM offers better management of clinical outcomes. For example, based on more accurate measurements of blood pressure variability, ABPM demonstrates that taking antihypertensive medication at night leads to better controlled nocturnal blood pressure, which translates into less end organ damage and fewer clinical complications of hypertension. For these reasons, albeit some shortcomings which were discussed, ABPM should be considered as a first-line tool for diagnosing and managing hypertension.

Health Outcomes of Traumatic Brain Injury Among Refugee Survivors of Torture.

Objective:To compare spontaneous reporting of health complaints in a sample of refugee survivors of torture with a history of moderate/severe traumatic brain injury (TBI) with survivors of torture without TBI and analyze the contribution of posttraumatic stress disorder symptoms to health outcomes. Participants:Treatment-seeking refugee survivors of torture with a moderate/severe TBI (n = 85) and a control group (n = 72) of survivors who suffered a physical injury during their persecution but had no history of a head injury. Measures:Health outcomes included a self-report of general physical health (scale 1-5), number of medical visits, and a scaled score of the number of health complaints. The Harvard Trauma Questionnaire (HTQ) was used to measure posttraumatic stress disorder. Results:Moderate/severe TBI was associated with more health complaints but not higher HTQ scores. TBI and HTQ scores are independently associated with a greater number of health complaints, and an interaction between TBI and HTQ scores suggests that the relationship between moderate/severe TBI and the number of health complaints strengthened with increased posttraumatic stress disorder symptom severity. Conclusions:Health complaints may be a common expression of psychological trauma, and service providers should be certain to explore both medical and psychological contributors when assessing refugee survivors of torture.

Teaching global health with simulations and case discussions in a medical student selective.

BackgroundAmong US medical schools, demand for Global Health (GH) programs continues to grow. At the same time, cultural competency training has become a priority for medical students who will care for an increasingly diverse US patient population. We describe a pilot period for a new GH Selective designed to introduce medical students to global medicine and enhance culturally-sensitive communication skills.MethodsAs a 4-week clinical clerkship, the GH Selective was offered annually over a three-year period to a total of 33 students. Activities included clinical assignments, cultural competency and clinical skills simulations, patient case discussions in tropical medicine, journal clubs, and lectures. Faculty assessments of student performance and student evaluations of course content were focused on 6 course objectives, adapted from standardized GH objectives.ResultsFor each offering of the GH Selective, at least 40 faculty members and fellows volunteered over 200 teaching hours from 11 medical school departments. Student feedback was consistently positive through competency-based curricular evaluations. As a result of its successes, the course is now offered on a biannual basis.DiscussionExperiential, student-centered teaching employed in this course proved successful as an introduction to delivery of evidence-based and culturally sensitive GH. Special emphasis on working with standardized patients in interdisciplinary and cross-cultural simulations provided students with clinical skills applicable for care provided both locally and on international rotations.ConclusionWith a special emphasis on cross-cultural sensitivity, this pilot elective trained future practitioners in fund of knowledge, clinical skills, and service delivery methods in GH.

Primary Care Screening Methods and Outcomes for Asylum Seekers in New York City

Effective screening in primary care among asylum-seekers in the US is critical as this population grows. This study aimed to evaluate disease prevalence and screening methods in this high-risk group. Two hundred ten new clients from 51 countries, plus Tibet, who were accepted into a program for asylum seekers from 2012 to 2014 were included. Screening rates and outcomes for infectious, non-communicable, and mental illnesses were evaluated. Screening rates were highest for PTSD, depression, hepatitis B, and latent tuberculosis. Seventy-one percent of clients screened positive for depression and 55 % for PTSD, followed by latent tuberculosis (41 %), hypertension (10 %), hepatitis B (9.4 %), and HIV (0.8 %). Overall screening rates were high. Point of care testing was more effective than testing that required a repeat visit. A large psychiatric and infectious disease burden was identified. These findings can inform future primary care screening efforts for asylum seekers in the US.

Management training in global health education: a Health Innovation Fellowship training program to bring healthcare to low-income communities in Central America

ABSTRACT Background: Interprofessional education is increasingly recognized as essential for health education worldwide. Although effective management, innovation, and entrepreneurship are necessary to improve health systems, business schools have been underrepresented in global health education. Central America needs more health professionals trained in health management and innovation to respond to health disparities, especially in rural communities. Objective: This paper explores the impact of the Health Innovation Fellowship (HIF), a new training program for practicing health professionals offered jointly by the Central American Healthcare Initiative and INCAE Business School, Costa Rica. Launched in 2014, HIF’s goal is to create a network of highly trained interdisciplinary health professionals in competencies to improve health of Central American communities through better health management. Methods: The program’s fellows carried out innovative healthcare projects in their local regions. The first three annual cohorts (total of 43 fellows) represented all health-related professions and sectors (private, public, and civil society) from six Central American countries. All fellows attended four 1-week, on-site modular training sessions, received ongoing mentorship, and stayed connected through formal and informal networks and webinars through which they exchange knowledge and support each other. CAHI stakeholders supported HIF financially. Results: Impact evaluation of the three-year pilot training program is positive: fellows improved their health management skills and more than 50% of the projects found either financial or political support for their implementation. Conclusions: HIF’s strengths include that both program leaders and trainees come from the Global South, and that HIF offers a platform to collaborate with partners in the Global North. By focusing on promoting innovation and management at a top business school in the region, HIF constitutes a novel capacity-building effort within global health education. HIF is a capacity-building effort that can be scaled up in the region and other low- and middle-income countries.

Empathy in graduate medical education milestones

Introduction Competencies in both empathy and cross-cultural health care are considered essential skills for physicians. A bedside learning activity was developed and piloted to define and teach empathy for residents, in order to improve clinical skills in cross-cultural patient care. Methods This activity was done on an inpatient medicine teaching service at Bellevue Hospital Center and New York University School of Medicine in New York City. Twenty-nine residents in internal medicine and thirteen faculty participated in one bedside session each. The objective of this exercise was to help the learner utilize empathy to: 1) gauge a patient’s identity and culture; 2) assess health literacy; and 3) change clinical management. Patients with communication barriers were interviewed with the BATHE technique (Stuart, Lieberman, 2008). All participants received anonymous surveys. Results 76% of participating residents agreed this activity improved their ability to provide cross-cultural care, 87% agreed it assessed their patient’s health literacy, and 87% agreed it changed their clinical management. Conclusions Empathy offers a promising bedside exercise in which to gauge health literacy and to demonstrate effective cross-cultural patient care. Based on this experience, an instructor’s guide was written for faculty, for use in training residents in empathy and cross-cultural patient care. Practice Points 1. Competencies in empathy and cross-cultural patient care are essential skills for physicians. 2. The BATHE empathy technique improves cross-cultural communication, changes clinical management, and improves patient outcomes. 3. Based on this pilot experience, an instructor’s guide was written for faculty to facilitate their own bedside teaching sessions on empathy.

A New Risk Factor for Cardiovascular Disease and Associated Risk Factors: Education

In this issue of the Journal, Di Chiara and colleagues conducted a cross-sectional study in which they evaluated the association between low education and higher global cardiovascular risk. The study included 228 outpatients (128 women) in a low education group (<10 years of education) and 260 outpatients (120 women) in a medium-high education group (10– 15 years of education). Individuals with psychiatric illness or alcohol use disorder were excluded. Left ventricular mass index and ejection fraction were measured by echocardiography and E/A ratio was measured by pulsed-wave Doppler. Visceral obesity, hypertension, metabolic syndrome, and microalbuminuria were measured for both groups. A regression model was used to test the independent role of education level and cardiometabolic markers for global cardiovascular risk. In brief, the authors concluded that low education was associated with a significantly higher prevalence of visceral obesity, hypertension, metabolic syndrome, and microalbuminuria, thus demonstrating greater global cardiovascular risk associated with lower education in this urban population in Sicily. As a social determinant of health, the link between education and health is being increasingly studied worldwide, with special attention to noncommunicable diseases (NCDs) in global public health. Two of every three deaths in the world result from NCDs, with four of five deaths in lowand middle-income countries. As a result, NCDs are widely recognized as a socioeconomic development issue worldwide. In 2008, World Health Organization released a report on its Commission on Social Determinants of Health, which details many underlying social factors that contribute to global health disparities. Not surprisingly, the first recommendation to improve daily living conditions for disadvantaged populations is to improve education for girls and boys everywhere. Without this, nutrition, psychosocial development, earning potential, and preventive medicine all suffer. Preventive medicine is inherently linked to NCDs through the primary health care management of chronic disease. According to the Lancet’s landmark Global Burden of Disease 2010 study, hypertension is now the number one risk factor for causing disease worldwide, and, consequently, ischemic heart disease is the leading cause of disability-adjusted life years. This has not always been the case, and the shift from infectious diseases to NCDs is considered a major epidemiological transition in recent history. This epidemiological shift can be understood through three rapid transitions: population growth and aging are increasing the disease burden from NCDs; improved education and rising income are leading to decreased mortality from infectious, maternal and child, and nutritional diseases; and people are living longer with chronic diseases: “what ails you is not what kills you.” Like education, the association of culture to health is increasingly being explored. First, global health has transitioned from a disease-oriented approach to a systems-focused strategy, which involves all stakeholders that govern and maintain healthy societies. Similarly, health education worldwide is reorganizing its priorities into interprofessional, systems-based frameworks that call for improving our educational focus for both patients and health professional students. Of course, each of these approaches require culturally appropriate design and interventions to succeed. In the 2014 Lancet Commission on Culture and Health, health and culture were considered to be so closely interrelated that “disentangement is impossible. From this perspective, the role of education in shaping one’s cultural understanding of health and well-being is essential. At the patient level, Kleinman’s Eight Questions are recognized as an important tool for providers to gauge their patients’ understanding of health and well-being. These questions ask patients what they call the problem at hand, what they believe is the cause of the problem, how does this problem affect their body and mind, and others. A compelling illustration of this patientcentered interview is eloquently captured by a recent study on culture and health: “In our country tortilla doesn’t make us fat: cultural factors influencing lifestyle goal-setting for overweight and obese urban, Latina patients.” To illustrate strategies to provide culturally appropriate health care worldwide, task shifting is emerging as a key approach to combating NCDs at the community level. Task shifting takes evidence-based health care services out of the hands of the relatively few physicians and other health-care system leaders, who often do not share the same cultural background as communities they serve, and into the hands of community health workers and other frontline primary health-care professionals, who have a greater workforce supply, come from and live in the communities they serve, and Address for correspondence: Mehmet Kanbay, MD, Koc € Universitesi Tıp Fak€ ultesi, Sariyer, Istanbul, Turkey 03490 E-mails: drkanbay@yahoo.com; mkanbay@ku.edu.tr