Report on rotation in Vientiane, Lao PDR

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Report on rotation in Vientiane, Lao PDR

• Renée Cassidy
• Medicine-Pediatrics PGY 3
• March 2003

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Overview

• Introduction to Lao
• Lao Health Care
• My Lao Experience
• Living Arrangements and Schedule
• Internal Medicine Experience
• Pediatric Experience
• Links
• References

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Laos

• Formally known as Lao Peoples Democratic
  Republic, or Lao PDR
• Informally Lao, as the S was mistakenly added
  by the French
• Landlocked nation bordering China, Vietnam,
  Myanmar, Thailand, and Cambodia
• Language is Lao, similar to Thai, a monosyllabic
  tonal language
• Many ethnicities populate Lao, including Lao
  Loum, Lao Tai, Lao Theung, and Lao Sung

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Lao

• Population is approximately 5 to 5.5 million
• Government is single party, communist, with much
  bureaucratic oversight and little economic
  freedom on a policy level
• Climate is tropical, generally from a low of 15
  C (59 F) to high of 38 C (100 F)
• Economy is predominantly agricultural, with
  considerable foreign aid from Thailand, the US,
  Australia, Malaysia, and France

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Lao

• About 70 of the land is mountainous and 50
  forested the Mekong River runs through Laos from
  China to Thailand
• Public education is generally poor and private
  education is expensive. School dropout rates and
  literacy rates are each around 60 .
• Theravada Buddhism is the most common religion
• Culturally the Lao are known as laid-back,
  hospitable, devout, and sociable

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Health Care in Lao

• Life expectancy is about 54 years (US around 77
  years)
• Infant mortality is 93/1000 (US about 7)
• Child mortality is 137-153/1000 (US 7-9)
• Health expenditures are 2-3 of the GDP (US
  13-14)
• No health insurance most health care expenses
  paid out-of-pocket

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Health Care in Lao

• Majority of people see physicians only when ill
  and often when illness is advanced
• Hospitals are poorly staffed and equipped, with
  restricted access to medicines, and are often far
  from villagers
• Approximately 24 physicians and 108 nurses per
  100,000 population (compared to US 279 physicians
  and 972 nurses)
• Many use traditional medicines and remedies

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Medical Education in Lao

• After high school students enter directly into
  medical school, a 5-7 year program encompassing
  premedical studies and basic sciences
• Little clinical learning is provided
• Books and other resources are not widely
  available
• Very few Lao language materials exist, thus many
  books are Thai, French, English, Russian
• Physicians practice immediately after finishing
  medical school, provided they can find a job
• Many express significant discomfort with their
  experience not ready to treat patients

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Medical Education in Lao

• No structured residency training exists in the
  country
• Those with enough money or with scholarships
  trained in France, Germany, Australia, Thailand,
  etc.
• In the last decade or so, NGOs have assisted the
  National University of Lao PDR Faculty of Medical
  Sciences to create pediatrics and
  obstetrics/gynecology residencies
• An internal medicine residency was begun last
  year
• Currently there are 6 positions per year for
  pediatric residents and 6 for internal medicine.

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Internal Medicine Experience

• Worked primarily in Mahosot Hospital but also
  visited Hôpital de lAmitié and Setthathirat
  Hospital
• Conferences, lectures, and bedside teaching as
  well as time for reading and research
• Case presentation on syphilis and lecture on
  hyponatremia

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Internal Medicine Experience

• 31 yo F from the provinces with several months of
  worsening fatigue, irregular menstruation,
  constipation who had mild thyromegaly on exam
• 20 yo M who presented pale and fatigued
• 30 yo F with inability to walk and headache who
  had nystagmus, paraplegia of the lower
  extremities, right weaker than left, and
  bilateral Babinski signs
• 37 yo M from Vientiane with fever and bright red
  blood per rectum

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Interesting Cases and Frustrations

• The 31 yo F with fatigue and thyromegaly was
  suspected of having hypothyroidism due to iodine
  deficiency, although Hashimotos thyroiditis is
  also relatively common. She couldnt afford the
  TSH and T4 (20), and when assistance was offered
  she declined anyway because she and her husband
  needed to return home and the lab only drew blood
  and ran the tests once daily.
• 20 yo M who presented pale and fatigued had a CBC
  of WBCs 2.4, Hemoglobin 6, Hematocrit 19, and
  Platelets 85,000. Aplastic anemia is extremely
  common in Lao and Northern Thailand with as yet
  no identified reason.
• The 30 yo F with neurologic signs was unable to
  afford a CT scan which was recommended (65).
  Her family wished to take her home although she
  was still unsteady walking, even with assistance.

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Interesting Cases and Frustrations

• The 37 yo M with bright red blood per rectum was
  obtunded in the ICU, BP 80/50, IVF at 50 ml/hr,
  H/H 4/12 awaiting a blood transfusion because the
  blood bank had no blood. Someone went to
  Thailand to request blood and an ambulance, which
  arrived just as the local blood bank delivered 3
  units donated for him. He was transferred to a
  larger hospital in Thailand where he underwent
  colonoscopy showing ulcerations in the ileum and
  a Dieulafoy lesion in the cecum. He was treated
  by epinephrine injection and cautery, received a
  total of 17 units of blood, and survived. He was
  suspected to have underlying S. typhi (Typhoid
  fever) causing the ulcerations, fever, and other
  systemic signs.

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Dieulafoy Lesions

• Dilated, tortuous submucosal vessel with an
  overlying small erosive defect in the epithelium
• Most commonly found in the upper half of the
  stomach but has been described in all areas of
  the GI tract
• Unclear etiology may be related to ischemia,
  vascular abnormalities, or other mucosal defects
• Typically diagnosed by endoscopy but angiography
  may be useful
• Endoscopic treatments include epinephrine
  injections, electrocautery, hemoclipping, band
  ligation typically epi is followed by cautery
• Surgical intervention may be required for lesions
  which rebleed or are difficult to reach
  endoscopically
• Rebleeding occurs in 10-40, attributed to large
  underlying arteries

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Typhoid Fever

• Systemic Salmonella infection caused by S.
  enterica serotype typhi (S. typhi) or other
  similar Salmonella serotypes
• Estimated 16 million cases annually, with 600,000
  deaths overwhelmingly in developing countries
• Transmitted by contaminated food or water (feces
  or urine) containing 1000-1,000,000 organisms
  lower infectious dose if gastric pH is high
• Diagnosed by blood cultures which are positive in
  60-80 bone marrow cultures, which are positive
  in 80-95 or by clinical suspicion in an endemic
  area
• Initially the bacteria multiply in mesenteric
  lymph nodes, then infect mononuclear phagocytes,
  then are released into the bloodstream.
  Secondary bacteremia leads to multiple organ
  infection, most commonly liver, spleen, bone
  marrow, gallbladder, and GI tract

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Clinical Features of Typhoid Fever

• Incubation is 7 to 20 days
• Initial symptoms are malaise, headache, dry
  cough, low grade fever (about 1 week)
• Progresses in the second week to high sustained
  fever (39-40 C), transient rose spots (2-4 mm
  pinkish blanching maculopapules), abdominal pain,
  hepatosplenomegaly, apathy, toxic appearance
• 3rd and 4th weeks are characterized by
  significant toxicity, neurologic signs,
  hemodynamic instability, complications, and death
• Where typhoid is endemic, it may be confused with
  malaria, tuberculosis, amebic liver abscess,
  influenza, dengue fever, leptospirosis,
  mononucleosis, endocarditis, brucellosis, typhus,
  visceral leishmaniasis, toxoplasmosis, neoplasia
  or connective tissue disease.

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Clinical Features of Typhoid Fever

• Complications include GI bleeding or perforation,
  often due to ulceration of Peyers patches in the
  terminal ileum encephalopathy or myocarditis
• Relapse occurs in 10-20 about 2-3 weeks after
  the fever breaks this is usually less serious
  than the initial bout
• Chronic carriage occurs in 1-5 and the organism
  is shed in feces or occasionally in urine
  (particularly in those with Schistosomiasis)
• Most cases are managed as an outpatient with oral
  antibiotics

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Treatment and Prevention

• Fluoroquinolones (ofloxacin, ciprofloxacin,
  pefloxacin) are very effective
• 3rd generation cephalosporins (ceftriaxone,
  cefotaxime) are an alternative in severe disease
• Resistance is found to chloramphenicol,
  ampicillin, TMP/SMX, and often multiple drugs
  concurrently
• Dexamethasone decreases mortality in severe
  disease
• Treatment is for 5-7 days in mild disease and
  10-14 days in severe
• Two vaccines are available an oral, attenuated
  vaccine lasting about 5 years and a parenteral
  vaccine lasting about 2 years
• Improved sanitation, water quality, and living
  conditions would significantly reduce the
  transmission

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Internal Medicine Experience

• Malaria
• Dengue Fever
• Typhoid Fever
• Hypertension
• Stroke
• Jaundice
• Aplastic Anemia
• Opisthorchiasis

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Pediatrics Experience

• Spent majority of time on Mahosot Hospital wards
  and Diarrheal/Infectious disease wards but also
  saw cases in the outpatient department, NICU, and
  PICU.
• Conferences, lectures, journal club, and bedside
  teaching, pre-rounding and rounding on patients
  as well as time for reading and research

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Pediatrics Experience

• Rheumatic fever and Rheumatic heart disease
• Vomiting, diarrhea and dehydration
• Typhoid fever
• Tetanus
• Measles
• Pneumonia and pleural effusions
• Malaria
• Dengue Fever
• Leukemia
• Aplastic Anemia
• Thalassemia
• Sepsis

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Links

• www.healthfrontiers.org Health Frontiers is a
  non-profit organization which currently
  administers the residencies in Lao and donates to
  the care of the Lao people
• www.theboatlanding.com an excellent Lao website
  which has links to many travel and tourism sites,
  recommendations for how to get the best out of a
  trip to Lao, and information about the Lao people
  and Luang Nam Tha
• www.who.int/country/lao/en/ - World Health
  Organization information about Lao
• www.heritage.org/research/features/index/ - The
  Wall Street Journal / Heritage Foundation annual
  ratings of individual countries economies
• www.bryanwatt.com Bryan is the husband of the
  current pediatric residency coordinator and a
  professional photographer
• www.gushurst.com Jordans and my home page,
  soon with photos of the trip to Lao and Viet Nam

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References

• Cummings, Joe. Laos, 4th ed. Lonely Planet
  Publications, Australia 2002.
• Eddleston, M. and Pierini, S. Oxford Handbook of
  Tropical Medicine. Oxford University Press,
  Oxford 1999, pp 206-7.
• Heritage Foundation and Wall Street Journal.
  Index of Economic Freedom 2003.
• Hohmann, E. L. Pathogenesis of Typhoid Fever,
  Treatment of Typhoid Fever, and Approach to the
  patient with Typhoid Fever. UpToDate version
  11.1.
• Mahosot Microbiology Review. Issue 2, April 2002.
• Norton, I. D., et al. Management and long-term
  prognosis of Dieulafoy lesion. Gastrointestinal
  Endoscopy 50(6) 762-7, 1999.
• Parry, C. M., et al. Typhoid Fever. NEJM
  347(22) 1770-81, 2002.
• Schmulewitz, N., and Baillie, J. Dieulafoy
  Lesions A review of 6 years of experience at a
  tertiary referral center. American J
  Gastroenterology 96(6) 1688-94, 2001.
• World Health Organization. Selected Health
  indicators for Lao Peoples Democratic Republic.