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Medicine in resource-limited settings

Medicine in resource-limited settings. October, 2009. HIV. 2008 Malawi HIV treatment guideline. http://www.aidstar-one.com/sites/default/files/AIDSTAR-One_Treatment_Summary_Table.pdf. Malaria. http://apps.who.int/malaria/docs/TreatmentGuidelines2006.pdf.

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Medicine in resource-limited settings

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  1. Medicine in resource-limited settings October, 2009

  2. HIV

  3. 2008 Malawi HIV treatment guideline

  4. http://www.aidstar-one.com/sites/default/files/AIDSTAR-One_Treatment_Summary_Table.pdfhttp://www.aidstar-one.com/sites/default/files/AIDSTAR-One_Treatment_Summary_Table.pdf

  5. Malaria

  6. http://apps.who.int/malaria/docs/TreatmentGuidelines2006.pdf

  7. Uncomplicated malaria in pregnant woman • Cochrane Review 2008 • Artesunate+atovaquone-proguanil vs. quinine • Amodiaquine vs. chloroquine • Amodiaquine+SP vs. chloroquine • Artesunate+SP, azithromycin+SP vs SP alone • Combination regimens may be more effective? Orton LC, Omari AAA. Cochrane Database Syst Rev. 2008 Oct 8;4

  8. Ascites • Transudate vs. exudate? (if you have laboratory support) • Ultrasound? • Differential diagnoses • Portal hypertension due to hep B, C, alcohol, schisto • Right sided cardiac failure and pericardial effusion • Nephrotic syndrome • Severe hypoproteinemia 2/2 malnutrition, HIV/AIDS • Tuberculosis • Malignancy

  9. Abdominal tuberculosis • High index of suspicion • Weight loss, abdominal pain, fever (1/2 of cases) • Peritoneal, ileal, or ileo-caecal • CXR normal in a large % of cases* • Median age 38 years • Diagnosis: ascitic tap, laparoscopy or laparotomy In resource-limited settings: When there is no ascites and/or poor laboratory support When laparoscopy is unavailable When the patient is too ill for laparotomy THERAPEUTIC TRIAL OF ANTI-TB TREATMENT! *Ramesh J et al. Abdominal tuberculosis in a district general hospital. Q J Med 2008; 101:189-95

  10. Dec-June 40,000 cases in 2006 Serogroups B & C in N. America and Europe African epidemics: A & C Asia: A Serogroup W135 in Saudi and W. Africa Treatment: X-pen + Chloramphenicol Ceftriaxone Vaccines Polysaccharide vaccines Monovalent against gp C for children/adolescent Acute Bacterial Meningitis Threats: Penicillin-resistant and chloramphenicol-resistant bacteria S. pneumoniae with reduced susceptibility to ceftriaxone The future rests with the provision of effective conjugate vaccines against S pneumoniae, H influenzae, and N meningitides to children in the poorest regions of the world!

  11. Seizures • Not eclampsia-related • Alcohol, diabetes, infection, previous SZ? • Diazepam 10 mg IV • Phenobarbitone up to 600 mg IV over 6 minutes • Phenytoin 15 mg/kg IV • Paraldehyde 5 cc IM • Phenobarb 60-180 mg/d as outpatient • Most are undertreated (20-40mg range)

  12. Anemia prevalence and risk factors • Urban Pakistan • 75% mild anemia (Hb <11); 15% moderate (Hb 7-8.9); less than 1% severe (<7) • Pica, tea consumption, and low intake of eggs and red meat • Urban and rural India • 32% mild anemia; 14% moderate; 2% severe • Protective factors: Muslim religion, high socioeconomic status Baig-Ansari N. Food Nutr Bull. 2008 Jun;29(2):132-9 Bentley ME. Eur J Clin Nutri. 2003;57(1):52-60

  13. Anemia in developing countries • Nutritional deficiencies • Iron, B12, folate • Chronic diseases • TB, HIV • Parasitic diseases • Hookworm • schistosomiasis • Malaria • Hemoglobinopathies At QECH, of patients with Hb <7, 79% HIV+, 1/3 with TB, 21% bacteremic (NTS), 14% malaria Hookworm common in HIV(-) Lewis DK. Trans. Of the Royal Soc. Of Trop. Med & Hyg 2005

  14. Treatment for Anemia • Improve diet • Iron, multivitamin if available, B-complex • Treat hookworm with albendazole/mebendazole • Treat schisto with praziquantel • HIV, TB screen

  15. Blood Transfusion • A National Blood Transfusion Service • Time lost when relying on family replacement blood donors • Paid donors and family blood donors are unsafe • Voluntary unpaid blood donation among low risk population groups • Quality assurance • Clinical guideline

  16. Epidemiology Acute (< 3 weeks) Virus: rota Bacteria: E. coli, Shigella, Campylobacter, Salmonella, Giardia, Entamoeba, Cryptosporidium, Vibrio Chronic Giardia, Campylobacter, Salmonella, MAI, Iso/micro, Stronglyloides, IBD, malabsorption Treatment Resistance to Bactrim, tetracycline and ampicillin ORS and/or IVF Antibiotics Cipro, Nalidixic acid TMP/SMX Metronidazole Albendazole Tetracycline, e-mycin or doxy for cholera Public Health Safe drinking water, latrines, hygiene Diarrhea Fever and blood: Shigella, campylobacter, Salmonella, EHEC INVESTIGATION?

  17. Sepsis syndrome • Fever, jaundice, oliguria, breathlessness, prostration, shock, encephalopathic • Blood film, CBC, glucose, CSF? • Diff: bacteremia, malaria, hepatitis, meningitis, encephalitis, pneumonia • HIV+ at higher risk for bacteremia • Empiric treatment: IVF, IV PCN and gentamicin+/- chloramphenicol or Ceftriaxone, ?IV Quinine

  18. Causes of sepsis variable • Northeast Thailand • S. aureus, pneumococci, other streptococci, E. coli, other Enterobacteriaceae, Pseudomonas spp., B. pseudomallei, leptospirosis, scrub typhus, dengue • Vientiane, Laos • Salmonella enterica, S. aureus, E. coli Cheng A C. PLoS Medicine August 2008.

  19. Syndromic management • Upper respiratory infection • Gastroenteritis • STD/STI • Genital ulcers • Lower abdominal pain/PID • Vaginal discharge • Fever, sepsis?

  20. Hypertension • ¾ of the world’s hypertensives (639 million) live in developing countries • Prevalence of HTN in females 15-49 in Jordan: 19% • 7.5% in the very young • 58% 45-49 years • Associated variables: education, marital status, parity, obesity, and dietary patterns Shakhatreh et al. Health Care for Women International 2008;29:39-53

  21. Managing hypertension • Low levels of awareness and inadequacy of treatment! • WHO criteria: >140/90 on at least 3 occasions • Urine dipstick, U&E? • Lifestyle modifications • High-risk patients benefit from antihypertensives even at lower BP readings • Meds: HCT, propanolol, methyldopa, ?captopril, nifedipine, hydralazine, furosemide • Polypill: thiazide diuretic, ACE inhibitor, beta blocker, statin, aspirin and folic acid

  22. Which of the following statements are true regarding hypertensive disorders in developing countries? • Calcium supplementation is recommended for women at high risk for hypertension in pregnancy • The proportion of premature death due to hypertension is much greater in high-income countries compared to low, middle-income countries • Hypertension prevalence is highest in women in the "former socialist countries" of Europe • It is more difficult to control BP in resource-limited settings

  23. The silent epidemic: diabetes • WHO predicts that developing countries will bear the brunt of this epidemic in the 21st century, with 80% of all new cases of diabetes expected to appear in the developing countries by 2025 • A person requiring insulin for survival in Zambia will live an average of 11 years; a person in Mali can expect to live for 30 months; in Mozambique a person requiring insulin will be dead within 12 months www.worlddiabetesfoundation.org

  24. Diabetes management • Think DKA in any patients with mental status change or septic appearance whether or not they are known to have diabetes! • DKA: IVF, soluble insulin, ?2-hourly monitoring, urine dip for ketones/glucose; glucometers are usually not available in the hospital • Outpatient management: • Oral agents: glibenclamide/glipizide, ?metformin • Soluble (2-3X a day) and lente insulin (1-2X a day) • When in doubt: 10 units • No self monitoring/home glucometer! • No refrigeration; reusing insulin syringes common!

  25. What are cost-effective strategies in improving pregnancy (and neonatal) outcomes in diabetic women? • Better screening and antenatal booking • Specialized diabetes care center • Scheduled cesarean section • Provision of self-monitoring of glucose (finger sticks or urine dip) • Improve availability of insulin and syringes • Effective diabetes education by community health workers

  26. Heart disease in Soweto • 1593 new cases of CV disease in 2006 at a tertiary care centre • 85% black Africans • 59% were women • Mean age was 53 years • Heart failure was the most common primary Dx • Dilated cardiomyopathy or hypertensive heart disease • 56% dx’d with hypertension • ¼ had valvular heart disease • Black Africans – more likely to have heart failure and less likely to have coronary disease Sliwa K et al. Spectrum of heart disease and risk factors in a black urban population in South Africa: a cohort study. Lancet 2008;371-:915-22

  27. Heart Failure • Peripartum - 1 in 100-1 in 1000 deliveries • Pericardial effusion (TB, KS, bacterial, malignancy) • BP (hypertensive cardiomyopathy) • HIV (viral cardiomyopathy) • Murmur (rheumatic heart disease) • Endomyocardial fibrosis (tropical regions of East, Central, and West Africa) • Treatment limited: • oxygen, morphine, aminophylline • furosemide, digoxin, captopril, B-blocker • isosorbide dinitrate/hydralazine combination?

  28. Asthma • Nebulised salbutamol and/or salbutamol inhaler • Prednisone 40 mg • Aminophylline 250mg IV • Inhaled corticosteroid usually not available • Oxygen if available • Environmental triggers?

  29. Mental Health • Low-income countries have an average of only five psychiatrists and one-and-a-half psychiatric nurses per million people. • Chad, Eritrea and Liberia have just one psychiatrist each* • Rule out organic causes of acute psychotic presentation (delirium) • Somatoform disorders • Conversion disorder • depression *http://allafrica.com/stories/200801250553.html?page=3

  30. Question • Which of the following are considered priorities in improving healthcare delivery in resource-limited setting? Which one can improve health/mortality? • Increasing the number of nurses, clinicians, and/or lab-rad technicians • Improved distribution of medications and supply (formulary and inventory) • CTs, MRIs, and advanced diagnostic testings • Improve training for health professionals • Technical support/consultants and volunteers • Informational management system • Operational research/quality improvement/EBM • Advocacy/change health policy • Strengthen public health infrastructure • Improve the socio-economic status of women

  31. Case 1: “worse on ART” • A 31 yo male presented with 2 weeks of mental status change, neck and backache, not talking, no bowel movements • Started on T30 (d4T/3TC/NVP) and CPT 2 weeks ago • A year ago, he was diagnosed with sputum negative PTB but only took 3 months of treatment • Exam: somnolent male, GCS 11/15; CN’s intact; no thrush; +neck stiffness; no focal spinal tenderness; no cLN; decreased BS at both bases with crepitus on the left; abdomen is distended with tympanic sounds throughout. Rectal tone is diminished with little stool. Both legs were very weak (1/5) with slt hyperreflexia. Bladder was full prior to catherization.

  32. Case 1 (continued) • WBC 8.0; Hb 12; CSF OP 35, glu 6; crypto Ag positive, Indian Ink neg; WBC 35 with lymphocyte predominance, +RBC; CXR ?bilateral diffuse interstitial infiltrates; abd flat film with large bowel distension • He was started on Diflucan 1200 mg/d and 3 days later, Decadron 8 mg IV (when his condition deteriorated) • 5 days into treatment, he became more alert with increased strength in his legs but left leg is much weaker than right. • Dx? Further management?

  33. AIDS 2008

  34. Case 2: “creepy crypto” • 38 yo male admitted for recurrent headache • Enrolled in the UNC crypto study 2 months ago when he was treated with Diflucan 1200mg->400mg/d, was improving until a week prior to admission • Started on T40 and CPT last month; CD4? • Indian Ink positive this adm; repeated LP every 2 days with high OP • Ampho B started this admission with clinical improvement

  35. Case 2 (continued) • Culture by UNC: CFU 450 (compared to 30K on initial dx) • Keep on Diflucan maintenance vs. Ampho B? • Duration of Ampho B? • Patient “absconded” when it was recommended that he stayed for at least 2 weeks

  36. UNC Project Malawi CM study, IAS 2009.

  37. Case 3 : another crypto • Lucious is a 39 yo male who was diagnosed with cryptococcal meningitis 4 weeks ago when he presented with headache and oral thrush. HIV was newly dx’d with CD4 12. He was started on fluconazole/flucytosine and CPT. He had repeated LPs for high OP and was discharged 2 weeks ago. • He returned with worsening headache and neckache, OP 45 on fluconazole 800 mg qd. U & E was normal except for sodium of 131 and he was started on amphotericin B.

  38. Case 3 (continued) • Logistics of Ampho B administration in resource-limited settings: • Central line • Prolonged hospitalization • Guardian, work • Nursing care • Availability of Ampho B • Laboratory monitoring

  39. Case 4: “pus around my heart” • 21 yo male admitted for severe dyspnea • Treated for sputum + PTB 6 months ago, improving until couple weeks prior to adm • ART started 2 months ago, CD4 212 • CXR with bilateral infiltrates and enlarged cardiac shadow • Large pericardial effusion noted with thickened fibrinous pericardium • 1.5L of dark yellowish fluid drained with symptomatic relief • Fluid sent for culture and sensitivity

  40. Case 4 (continued) • He was treated initially with X-pen + chloramphenicol, switched to Ceftriaxone • Concern for resistant TB? • KCH micro lab grew strep pneumo from pericardial fluid; pus drained on day 2 • Purulent drainage continued • Options: pericardial window, ?irrigation with streptokinase, ?antibiotics

  41. Case 5: TB Rx and ART option • GP is a 39 yo male presented in August 2008 with on/off headache for couple months, intermittent nausea/vomiting, weakness • Started on ART 3 years ago, initially on T40 and CPT then switch to AZT/3TC and Nevirapine due to ?n/v/?pancreatitis • CD4 76 in ’05; repeated=25 in 3/08; unclear adherence history • Had sputum negative for TB recently • Had headache 3 months ago, LP was negative X 2, also transient left sided weakness • Repeated CXR showed moderate right pleural effusion and infiltrate

  42. http://whqlibdoc.who.int/hq/2007/WHO_HTM_TB_2007.379_eng.pdf

  43. Public Health Approach to ARTScaling up controversies • Risks • Clinical eligibility criteria: patients in st 1,2 with immune dysfunction or pts in st 3,4 with high CD4 • Clinical outcome measures: viral resistance identified at later stage • Facilities to monitor CD4 and viral load? • COST! • Poor laboratory services • Health worker shortage • Treatment adherence • Medical errors from managing a more complex protocol

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