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  1. Report on rotation in Vientiane, Lao PDR Renée Cassidy Medicine-Pediatrics PGY 3 March 2003

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

  3. Laos • Formally known as Lao People’s 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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.

  10. Internal Medicine Experience • Worked primarily in Mahosot Hospital but also visited Hôpital de l’Amitié and Setthathirat Hospital • Conferences, lectures, and bedside teaching as well as time for reading and research • Case presentation on syphilis and lecture on hyponatremia

  11. 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

  12. Interesting Cases– and Frustrations • The 31 yo F with fatigue and thyromegaly was suspected of having hypothyroidism due to iodine deficiency, although Hashimoto’s thyroiditis is also relatively common. She couldn’t 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.

  13. 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.

  14. 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

  15. 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

  16. 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.

  17. Clinical Features of Typhoid Fever • Complications include GI bleeding or perforation, often due to ulceration of Peyer’s 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

  18. 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

  19. Internal Medicine Experience • Malaria • Dengue Fever • Typhoid Fever • Hypertension • Stroke • Jaundice • Aplastic Anemia • Opisthorchiasis

  20. 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

  21. 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

  22. Links • – Health Frontiers is a non-profit organization which currently administers the residencies in Lao and donates to the care of the Lao people • – 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 • - World Health Organization information about Lao • - The Wall Street Journal / Heritage Foundation annual ratings of individual countries’ economies • – Bryan is the husband of the current pediatric residency coordinator and a professional photographer • – Jordan’s and my home page, soon with photos of the trip to Lao and Viet Nam

  23. 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 People’s Democratic Republic.