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Student editor

What does it mean to celebrate International Women’s Day in health and medicine?

9 Mar, 17 | by Jenny Thomas

By Manasi Jiwrajka

We look back at some of our case reports:

Gender remains an important determinant of health. For example, in HIV in India: the Jogini culture , we read that female gender ensured a lifestyle that exposed the patient to HIV.1

“The patient never attended school. At menstruation, she awoke to a startling reality as she had her first sexual encounter in her parent’s home.”

Another case from India reports that more women and girls are illiterate compared to men (41.2% and 21.4% respectively).2 Karande states that “maternal illiteracy directly affect[s] health-seeking behaviours,” and in this case, maternal illiteracy as well as maternal undernutrition results in infantile iatrogenic Cushing syndrome.

In this case from the USA, a patient without prenatal care has devastating consequences by attempting to deliver at home. 3

Sometimes, being a female is uncertain in and of itself as in intersex individuals or rare conditions such as female hypospadias, which may be recognised early in the patient’s life or much later.4,5 Some females have had gender reassignment surgery, and were previously males. The surgical intervention to become a female may lead to complications.

Vaginal reconstruction does come with a myriad of complications including rectovaginal fistula, urethral fistula, vaginal stenosis, with loss of either depth or width, urethral stenosis, hair growth in the vaginal canal if scrotal skin is used for construction6

Women’s health is often equated to maternal health or gynaecological health but women’s global health includes cases such as the following:

  1. Mental health in a Dominican, HIV+ woman who was scared of being considered “loca” and promiscuous. The authors write:

“Although the patient voiced suicidal intent, she was reluctant to see the psychologist for fear of being labelled as a ‘loca’ (crazy person). Locas are rejected in Dominican society for being perceived as being out-of-control, unpredictable and unable to fulfil expected gender roles…HIV-positive women are often negatively perceived as sexually promiscuous, which can be considered an insult to their partners’ ‘machismo’ (sense of manliness), and women who disclose their serostatus are at a greater risk of abandonment and abuse by their partners.” 7

  1. Multiple Sclerosis in an anaesthesiologist from Trinidad and Tobago: MS incidence is higher among females, and the burden of the disease is high for any patient especially for someone working in “a medical specialty with a high level of stress and long hours of exposure and night shifts.” The patient, and the doctor, in this case writes:

“For those who read this article, just be part of those who are disclosing this global health problem for the well-being of many.”8

Women around the world are facing significant health issues both as patients and doctors. Some emerging priorities for women’s health globally are well outlined in this paper by Temmerman et al.9

  1. Restricted physical activity among women due to social norms
  2. Tobacco use, maternal smoking and COPD
  3. Women’s cancers such as breast cancer, and cervical cancer
  4. Conditions of older age without adequate treatment
  5. Structural determinants of women’s health

Women in health are also celebrating today that we have come a long way to become anaesthesiologists, surgeons, gynaecologists and urologists.

References:

  1. Borick J. HIV in India: the Jogini culture. BMJ Case Reports. 2014;2014.
  2. Karande S. Consequences of low birth weight, maternal illiteracy and poor access to medical care in rural India: infantile iatrogenic Cushing syndrome. BMJ Case Reports. 2015;2015.
  3. Kumar N, Gilbert L, Ellis T, Krishnan S. Consequences of delivery at home in a woman without prenatal care. BMJ Case Reports. 2017;2017.
  4. Prakash G, Singh M, Goel A, Jhanwar A. Female hypospadias presenting with urinary retention and renal failure in an adolescent: uncommon and late presentation with significant hidden morbidity. BMJ Case Reports. 2016;2016.
  5. D’Cunha AR, Kurian JJ, Jacob TJK. Idiopathic female pseudohermaphroditism with urethral duplication and female hypospadias. BMJ Case Reports. 2016;2016.
  6. Rezwan N, Basit AA, Andrews H. Bilateral ureteric obstruction: an unusual complication of male-to-female gender reassignment surgery. BMJ Case Reports. 2014;2014.
  7. Santoso LF, Erkkinen EE, Deb A, Adon C. HIV-associated dementia in the Dominican Republic: a consequence of stigma, domestic abuse and limited health literacy. BMJ Case Reports. 2016;2016.
  8. Reyes AJ, Ramcharan K, Sharma S. Multiple sclerosis in a postgraduate student of anaesthesia: illness in doctors and fitness to practice. BMJ Case Reports. 2016;2016.
  9. Temmerman M, Khosla R, Laski L, Mathews Z, Say L. Women’s health priorities and interventions. BMJ : British Medical Journal. 2015;351.

Back to Basics with Female Genital Mutilation

6 Feb, 17 | by Jenny Thomas

By Manasi Jiwrajka

The 6th of February marks the International Day of Zero Tolerance to Female Genital Mutilation.

Last year I had the privilege to listen to Khadija Gbla at the Global Health Conference in Newcastle, Australia organised by the Australian Medical Student Association. Khadija is the voice and face of female genital mutilation (FGM) in Australia and worldwide. She addressed an audience of ambitious future doctors interested in global health, and what struck me was the simple message: take a good history and examine the patient.

As junior doctors and medical students, we often forget that we may be closer to patients than anyone else because there is not that white coat barrier between the patient and us. We forget that although we don’t always make major clinical decisions, the information we relay to our seniors is what determines their clinical decision, and as such a thorough history and examination is crucial.

Patients who have had FGM inflicted on them may present with common symptoms such as  incontinence, dysmenorrhea, dyspareunia or all of these. In this case report by Abdulcadir and Dallenbach 1, a 27 -year old female presents with the above symptoms after having consulted a gynaecologist. They write:

“She had been living in Europe for more than 5 years and mentioned having consulted a gynaecologist some years ago, but no treatment had been proposed. She added that she had felt uncomfortable because the physician did not seem familiar with FGM/C. After that experience, she never consulted again in spite of worsening symptoms.”(Abdulcadir and Dällenbach 2013)

One of the key learning points from the case report, as authors write, is “Overactive bladder post female genital mutilation/cutting type III is a very distressing condition, probably under-reported due to shame, poor medical reception and cultural barriers.” We in the medical profession can at least make ourselves aware of FGM and reduce the stigma associated with this.

Khadija’s message to us still holds true. When in doubt, ask. When in doubt, examine.

Here is a video of another one of Khadija’s inspiring talks: https://www.ted.com/talks/khadija_gbla_my_mother_s_strange_definition_of_empowerment

 

References

1 Abdulcadir, J. and P. Dällenbach (2013). “Overactive bladder after female genital mutilation/cutting (FGM/C) type III”. BMJ Case Reports 2013. http://casereports.bmj.com/content/2013/bcr-2012-008155.full (accessed 03.02.2017).

Global Health Workshop, University of Queensland, Brisbane, Australia with Dr Seema Biswas, BMJ Case Reports Editor in Chief

12 Jan, 17 | by Jenny Thomas

By Manasi Jiwrajka

In October, 2016, we conducted a Global Health workshop at the University of Queensland in Brisbane, Australia.

We advertised the event to medical and dental school students, and had an overwhelming interest in the workshop. We had attendees ranging from first year medical students to faculty members at the University of Queensland.

Prof Mieke van Driel, Deputy Head of the School of Medicine and Head of General Practice at the University of Queensland, opened the workshop with her definition of global health, and her experiences working with Medecins Sans Frontier. Her inspirational opening talk paved way for the workshop, and to hear our guest speaker Miss Seema Biswas, EIC of BMJ Case Reports and a war surgeon with the Red Cross.

Miss Biswas said that global health is just health. She also discussed the importance of humanitarian aid and how case reports are crucial in advocating for individuals and their health. One message from Miss Biswas’s talk that resonated with me and other students is that global health is not merely health overseas or abroad, but global in the sense of taking care of all the patients’ issues and addressing the social determinants of our patients’ health.

The workshop involved two breakout sessions. In the first, the attendees wrote on flip charts about the global health projects they have undertaken so far, and what they would like to do in the future.  Students talked about their elective experiences in Haiti, the Philippines, in rural and urban Australia. We discussed where the students see their career in global health.

Miss Biswas also inspired students to write up their own case reports from their daily experiences with patients. It reminded us that any patient we see is a global health case on their own. As such, in the second workshop students used the BMJ Case Reports template to write a case report of their own using their experiences with patients, and we came up with a global health problem list. This was followed by a discussion on how addressing the social determinants of our patients’ health can result in improving health and access to health.

The global health workshop has been a great success, and we have received incredible feedback from the students. During the workshop we created a mailing list, through which the global health discussion continues, and we look forward to many more workshops in Brisbane and around Australia!

A dentist with training wheels

8 Dec, 16 | by Jenny Thomas

By Nandini Sharma

In the United States the third year of dental school serves as the first clinical year of dental education. During this year we are expected to translate our first two years of didactic knowledge into full time patient care. By the end of my second year I was more than eager to get away from the constant barrage of examinations and start to treat patients. I expected the transition from treating a plastic tooth to a real patient to be difficult. What I didn’t expect was to learn was how social determinants of health can affect oral health.

Recently, I admitted a patient who exemplified how these factors influence oral health. She was a 24-year-old African American female who had braces placed at age 14 and has never had them removed. The patient complained of pain in her mouth and said she had recently been to the emergency room because of a dental abscess. The emergency room gave her amoxicillin to treat the infection and recommended finding care at the dental school. In 2014 the Journal of American Dental Association found emergency department visits for dental problems cost almost $3 billion from 2008-2010. The study also found that individuals who are uninsured and live in a low-income area are more likely to visit hospital-based settings for urgent dental care (1).

During her oral examination she presented with heavy calculus on her teeth, missing teeth, root tips, mobile teeth, generalized inflammation, and a chronic abscess on her maxillary palate. An endodontic resident was called in for a consult and used a palatal nerve block before draining the abscess (2). I realized she would need to have all her maxillary teeth extracted for immediate dentures. As a provider it was very difficult for me to tell a 24-year-old patient that she will need dentures. Although complete denture prosthodontics is a routine, inexpensive treatment option, it is a last resort.

As dental students we sink our teeth into clinical practice by treating a diverse, underserved population. This provides us with a unique insight on how social, physical, and behavioral barriers prevent our patients from attaining oral health care (3,4). My patient disclosed that her mother would take her for orthodontic check-ups when she was younger. But at the age of 19 she lost her mother and stopped visiting the dentist. Over time as the status of her oral health deteriorated she no longer felt the need to brush daily. For my patient one of her main deterrents of proper oral health care was psychosocial. Aside from treating dental disease we need to tailor our care based on which determinants are hindering our patients from having good oral health.

 

References:

  1. Allareddy, V., Rampa, S., Lee, M. K., Allareddy, V., & Nalliah, R. P. (2014). Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. The Journal of the American Dental Association145(4), 331-337.
  1. Fitch, M. T., Manthey, D. E., McGinnis, H. D., Nicks, B. A., & Pariyadath, M. (2007). Abscess incision and drainage. New England Journal of Medicine357(19), e20.
  1. Scheerman, J. F., Loveren, C., Meijel, B., Dusseldorp, E., Wartewig, E., Verrips, G. H., … & Empelen, P. (2016). Psychosocial correlates of oral hygiene behaviour in people aged 9 to 19–a systematic review with meta‐analysis. Community dentistry and oral epidemiology.
  1. Strauss, R. P., Stein, M. B., Edwards, J., & Nies, K. C. (2010). The impact of community-based dental education on students. Journal of Dental Education74(10 suppl), S42-S55.
  1. Greenspan, J. S. (2013). Global health and dental education: a tipping point?. Journal of dental education77(10), 1243-1244.

 

Why should students write a global health case report?

11 Jul, 16 | by Hemali Bedi

By Manasi Jiwrajka

Recently we published a paper on the reasons for medical students to write a Global Health  case report. We don’t often hear about a Global Health case report, and usually it is about something weird and wonderful that we have read in a Pathology text book.

Medical students find Global Health overarching

We, as students, often think that Global Health is a phenomenon that exists only in low-income countries. It also seems that our ‘I-am-just-a-med-student’ attitude stops us from realising that we may actually have an effect on how patients live and their determinants of health.

Capture

Perhaps this perception is because there is no universally accepted definition of Global Health and two, worldwide, there remain profound differences in Global Health education.

 

How can we define Global Health?

“We propose that the ‘global’ in Global Health does not refer so much to ‘overseas’ or ‘over there’, as it refers to ‘over here;’ the real definition of ‘global’ in Global Health is ‘health everywhere’. ‘Global’ also refers to ‘all’ aspects of health i.e. a holistic approach, essential to exploring and taking on the real causes of disease, the social determinants of health. This focuses our attention on the patient in front of us and what we need to do to prevent them from becoming ill again.” [1]

Why are Global Health case reports useful? Why should medical students write a Global Health case report?

  1. To look at the root causes of the illness
  2. To learn about society, economics, politics, cultures, and how they affect our patients
  3. Importance in every field
  4. Learn Global Health
  5. Publish and share these cases
  6. Create an evidence base
  7. Create change

 

References
[1] Jiwrajka M, Biswas S. Why should students write a global health case report? AMSJ 2016, Vol. 7(1)

Ottawa 2016 and ANZAHPE Conference

31 Mar, 16 | by Hemali Bedi

By Manasi Jiwrajka

The beautiful city of Perth on the Western Coast of Australia hosted the Ottawa 2016 and ANZAHPE conference this year. Delegates from the US, Canada, the UK, Netherlands, Indonesia, Hong Kong, China, South Africa, Australia and many other countries attended this conference. I downloaded the mobile app for this conference prior to my flight from Brisbane to Perth, and got a minute by minute update on the conferedited_IMG_20160322_144637ence.

There were several important medical education themes addressed during this conference from simulation in the context of medical education, OSCEs, peer tutoring, medical scientist, rural health program, global health, and empathy. My poster was titled ‘Why Should Students Write a Global Health Case Report?’, and I presented it to an eclectic audience that thanked me for my enthusiasm! Several educators approached me after the presentation for more information regarding their students writing case reports for the BMJ, and I reminded them of the elective competition that is due on April 30th.

Some of my favourite parts of the conference included (i) a talk on cultural competency, and including patients culture to provide individualised healthcare, (ii) the concept of ‘phenomics’, suggesting that a patient’s environment can affect their health prognosis, (iii) all the focus on feedback for students, (iv) how empathy levels can be altered following a reflection exercise, and is dependent on coping styles, (v) and acquiring loads of free pens!

I am looking forward to the next ANZAHPE conference in Adelaide next year.

Behaviour change: A bitter pill to swallow

29 Mar, 16 | by Hemali Bedi

By Kristian Dye

The case reported by Dunton et al comes from a very particular cultural context, and yet it demonstrates things that all practitioners see in almost all healthcare settings.

The patient reported is a 60 year old man with type 2 diabetes, who despite taking his medications, is unable to make the diabetes-592006_1920behaviour change that could impact the course of his disease.

The report looks at the complex nature of this phenomenon, that it is not as simplistic as ‘not wanting to change’, but that there are cultural and sociological issues at play.

The real question for clinicians across the globe for many long-term conditions is no longer how to treat them, but how to support patients to manage their own conditions.

What skills are most important for clinicians to facilitate the self-care that long-term conditions rely upon?

Steps to success

3 Feb, 16 | by Hemali Bedi

By Kristian Dye

Frates and Crane report a case that is a little unusual among case reports. The patient had no weird or wonderful signs or symptoms. She had no particular pathology. She was not unwell. Her presentation was all about lifestyle, risk, and the case is all about modification of that risk. walking-711789_1920

The patient in this case is an archetype for many patients seen in primary care. She is overweight, has elevated lipids, has a sedentary lifestyle and has a family history of stroke.

For me, this only really poses two questions:

1. What was different in this case to those who we can convince of the value of risk modification, but who are unable to achieve it?
2. How can we achieve these kinds of results for more of our patients?

Answering these questions could reduce morbidity and premature mortality among our populations much more radically than more glamourous, cutting-edge interventions.

 

Case Report: An 11-year-old boy with silico-tuberculosis attributable to secondary exposure to sandstone mining in central India

28 Aug, 15 | by Jenny Thomas

By Midhun Mohan

This is a case about an 11-year old who developed silicosis after being exposed to sandstone mining. Stone-mining is a lucrative industry producing billions of dollars in export every year. Despite being highly profitable, the health impacts of the industry are severely under researched.

The authors state that:

“no preventive measures have been instituted in the stone-mining industry and children are exposed to respirable silica dust when their mothers take them to their work places”

Despite the fact that legislation exists to protect these workers, employers disregard the law and turn a blind eye. Extreme poverty means these workers are not able to quit thus enduring these conditions to earn a living.

Why is the state not penalising the mine owners?

Simple answer – Corruption.

Corruption aids and amplifies this situation. The state ignores the problem since the industry generates much foreign exchange.

How can these poor families be empowered to take a stance against the mine owners?

Safer prescribing by empowering patients?

1 Jul, 15 | by Kristy Ebanks

By Kristian Dye

For this post, I have chosen to write about a Case Report that comes from the United Kingdom. It’s about a patient with a complex set of management challenges, however none of them are rare – and the United Kingdom is almost certainly one of the best places in the world to be with such a complex constellation of conditions.

So far, this does not sound like compelling global health territory, however it addresses a problem that is universal within health care systems globally – polypharmacy. This is an issue which affects certain populations more than others (for example, in elderly populations (1), an average of 2-9 medications are taken daily, with one in six (2) over 65s taking 10 or more daily).

The issue, in this case, is further complicated by the prescriptions not all originating from a single physician. In an older person, they maybe taking antihypertensives, a statin and drugs to reduce cardiovascular risk – however, they will likely all originate with the primary care physician.

The patient… is supported regularly by general practice, the school nurse, ear nose and throat specialists, general and community paediatrics, dietetics, specialist dentistry and ophthalmology’

From this list of involved specialties, the potential formulary that prescriptions will come from is probably as wide as in any case imaginable. This opens up an enormous range of potential drug interactions.

This is a real day-to-day patient safety issue faced in all healthcare settings, whether the system is well integrated or highly fragmented.

‘An example where the lack of an up-to-date medication list led to a potential medication-related problem was the prescription of azithromycin for an ear infection by an ENT surgeon. There is a documented drug interaction between azithromycin and domperidone, a medicine used regularly to treat the patient’s gasto-oesophageal reflux’

The solution suggested in the case is to centralise the patient’s records, but not in the way we usually imagine.

Integrated health care records are usually conceived of as a centralised database that healthcare workers are able to tap into and pull down records for their patient. These systems are highly resource intensive and logistically difficult to deliver over large geographical areas. The alternative is wonderfully elegant.

We trust our patients. If we ensure that when we prescribe something, we add it to a patient-held record, then we know that our colleagues will know what we have done, and are able to factor this in to their own treatment decisions. The solution in the case is a smartphone app (3), which is highly convenient for the more than 1.75 billion smartphone users (4) worldwide – however there’s no reason why a similar approach couldn’t be undertaken on old-fashioned paper for those who don’t have access to the technology – in the UK we’ve been doing this for child health (5) for years.

Surely, then, this seems like an easy decision. We can improve the safety of our patients, by trusting our patients. If we can trust patients with the risk of possessing the medicines, why not trust them with the records too?

  1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295469/
  2. http://www.bmj.com/content/347/bmj.f7033
  3. https://itunes.apple.com/gb/app/medication-passport/id595970381?mt=8
  4. http://www.emarketer.com/Article/Smartphone-Users-Worldwide-Will-Total-175-Billion-2014/1010536
  5. http://www.rcpch.ac.uk/improving-child-health/public-health/personal-child-health-record/personal-child-health-record

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