Recap! - Exploring the intriguing details of International Clinical Research in Uganda

By Prosperity Eneh

I have continued to learn and grow since Dr. Nicol and the 4th year students (Sara and Kunkun) went back to Minnesota. I have had the opportunity to focus more on clinical practice and research with the meningitis team here at IDI and Mulago/Kirrudu general hospital. I have also had the ability to dive deeper into organizing and finalizing logistics for the post-mortem drug distribution research study in HIV patients (learn more).

Preparing items for the post-mortem research study with Paul and Carol

I head back to Minnesota today and for this final reflection, I will break it down into the various aspects of international research work that were most intriguing to me for the past 10 weeks;

International clinical research - collaboration between institutions is vital for sustainability 

It has been very interesting to be plugged into a team that conducts clinical trials on a large scale. In the past when I have read published papers on big studies that have the potential to affect and change national guidelines, it is often hard to imagine the work that goes into ensuring that these clinical studies goes successfully. I have come to understand the intricacies of this sort of work and the level of organization, team work and perseverance that leads to success. The clinical research team in Uganda is often a mix of international and local partners with various roles to play. The team I worked with consisted of medical doctors, nurses, lab assistants, pharmacy personnel, clinical officers, administrative assistants, research assistants, and a few others. The partners in this team include personnel from Uganda, USA and London. Currently the team is preparing for about 3/4 major studies to start and there has been many training sessions. It is rewarding to contribute to these discussions from a pharmacy perspective but I would say more than the contributions, I have learned so much. 

Clinical rounds and its immediate patient benefits

The research team also conducts clinical rounds at the Mulago/Kirrudu General Hospital where patients with suspected or confirmed cryptococcal or tuberculosis meningitis are referred to. They see these patients in the infectious disease ward. During ongoing trials/studies, the patients can be consented and enrolled in trials if eligible, and when there is no ongoing trial, the patients are still seen and treated. It is however an interesting point to be made about availability of necessary supplies during studies versus when there isn't any studies ongoing. I refer to this as immediate benefits for the patients. In a previous post, I mentioned the lack of medications, labs and various other medical supplies needed for patients in the government hospitals. Often, patients are also unable to fund themselves to receive these vital medical supplies. However, when there are ongoing studies, the team often has funds available to provide these essential labs, medications and other medical supplies to the patients free of charge. Both those enrolled in the study and those that are not enrolled get to benefit from this supply. The impact can be life-saving. Prior to each day of clinical rounds, the team with the latest information on the patients, hands off to the clinical team for the day via phone discussions of the patients. The team is  also available in the infectious disease ward for questions regarding other non-meningitis patients.

Sub-projects, data analysis and publications

While there is often some bigger longer term studies ongoing with the clinical team, there are also opportunities for sub projects and other smaller data analysis projects. These offer opportunities for trainees to use data from large cohorts to answer other clinical questions. As one goes on clinical rounds and sees other potential research questions, it is common to see sub projects come out of these observations. The MN Uganda team has been a great training facility for many students, residents and fellows from various healthcare professions. There is often something for everyone that is dedicated to finding answers to questions. This has also led to very many publications that has come out of this group. During the weekly team phone call, sub-projects are also discussed and trainees are able to get mentorship and direction from the team on the direction of the various ongoing projects. During my stay in Uganda, we worked on a case report now submitted for publication involving a patient with concomitant HIV-Malaria and TB meningitis as this presented a unique case of drug-drug interaction in the management strategy. This is one example of how various activities can stem out of the bigger studies. It provides so many opportunities for the team to continue to add to the literature in this area. 

Regulatory bodies (IRB, NDA, UNSCT, SRC) - Ethical conduct of research is a big deal

There are many acronyms as you see above for the various regulatory bodies. In Uganda, I have noticed that ethical conduct of research is extremely important. While the process can often be tedious and discouraging, it is vital and ensures that patients are not taken advantage of in the research that is conducted. There are some policies that are strict and there are others that can take a long time to process. However, it is still all done as a way to weed out research that only benefits the researcher and not the local population. Changes to the protocol and other sub projects also have to go through the approval bodies as needed. I spent some time ensuring that our regulatory binder for the post-mortem drug study is up to date and while this was challenging, it was also very rewarding.  

Pharmacist role as part of the team - Drug-Drug interactions, medication management and unique perspectives

As pharmacists, we are trained to be the drug experts. I think the biggest contribution to the clinical research team comes from being knowledgeable about the medications. I found it hard at first, as the medications often have different names and I needed time to look up the generic name. However, as I got comfortable with the names of the drugs and their use in this patient setting, it became easier to make medication related recommendations to the medical officers. Furthermore, in my fellowship and Master’s program thus far, I have also been exposed to more extensive research principles which helped me tremendously in being a part of the research team. We spent many hours reviewing data collection instruments for upcoming studies. Providing the pharmacist perspective in relation to research instruments that will be used for the collection of medication information was unique. Also, as mentioned above, sub projects often stem from larger studies. One of the projects that I will be working on moving forward will involve looking at the large data collected from hospitalized patients enrolled in two previous studies and highlighting likelihood for drug-drug interactions and strategies to mitigate them in the future. I am excited to be able to collaborate with the Ugandan pharmacist and medical officer on this project. 

In conclusion

Goodbye lunch!

I will definitely miss Uganda! It has been such an amazing experience in all aspects. I hope to start making plans to visit again soon. I had a chance to meet up with the pharmacists I worked with while I was in Uganda for a goodbye lunch. They were great to work with and I am glad for their continued friendship moving forward. I am heading back to Minnesota for a while and then off to Glasgow, Scotland in September for the International Pharmaceutical Federation (FIP) Annual Conference!

Sara's Post-APPE Reflections

By Sara Brown

Today, we gave a presentation on pharmaceutical care in the US. We discussed how pharmacists have moved from being in a purely dispensing role to one that is more clinical-based. I realized I never had to work for this since I am entering pharmacy at a time when clinical pharmacists already have an established position, unlike in Uganda. Here, I have met pharmacists that have paved their way into their current role. They are working hard at being a mentor for young pharmacists to inspire them to step beyond a traditional dispensing role and into one of a clinician. It is a culture change that will take time to be accepted, adopted and implemented.

Looking back over the past month, it is hard to pick out a favorite day or memory (embedded are some great pictures, though). I experienced a lot of what Uganda had to offer: safaris, street food, plantains, fresh pineapple, Nile River rafting and more. However, I was also exposed to poverty, lack of healthcare resources and endemic infectious diseases.

My perception on Ugandan healthcare has dramatically changed. Beforehand, I was expecting primitive care. Now, I understand that doctors practice evidence-based medicine just like in the United States, but the lack of resources is the driving factor behind the difference in care. Having daily labs for a patient is something I never thought twice about, before coming to Uganda. From my experience in these different hospitals, daily labs are not possible. Oftentimes, the patient’s family cannot afford to get labs done. Or, there is no family member present to bring the sample to the lab. Or, the hospital is lacking the resources to get the sample processed. It is a problem I have never been exposed to before and I realized I have taken so much for granted.

I have also grown in character in the past month, partly due to being abroad, but also due to having experience as an almost-pharmacist. By participating in rounds, answering questions and making drug therapy recommendations, I am gaining valuable knowledge and experiences that increase my confidence.

I will miss aspects of Uganda: the warm hospitality of people, the beautiful weather, the slower pace and the relaxed atmosphere. The fresh fruit is incredible, too. However, I am thankful to leave the steep hills and traffic behind! I am very glad I participated in this APPE, I would highly recommend it!

Kunkun's APPE Reflections

By Kunkun Wang

I can’t believe this rotation is  coming to the end and we are leaving. It is hard to summarize and reflect on this unique APPE experience because it’s just so different from anything else and I have learned so much from it.

It’s a perfect rotation that composed of almost everything possible: research, hospital pharmacy, clinic pharmacy, public health areas such as policy making and health system administration, and the coolest part, going to the morgue and watching autopsy!

My favorite part is the antimicrobial stewardship. When I knew that I would be working on an antimicrobial stewardship project, I thought it was going to be a very complicated process. I thought I might need to know all of the infections and what were the appropriate drugs for them. After Eva (pharmacist working at IDI) explained the background and needs of IDI, we decided to make a quick reference for clinicians and some educational tools for the patients. The tools we made were actually very simple and straightforward. I also enjoyed the patient interactions when we tested our tools on patient representatives. We had so many lectures in pharmacy school talking about patient education: how you need to be patient friendly, avoid technical terms, use simple language, clarify questions, etc. I thought our tool met all the requirement with simple words and pictures, but we still confused and scared our patient. We jumped to antibiotic resistance issue right away and told our poor patient that you might get some bad bug and no drug would work. Some term we thought simple enough: antibiotics, virus, bacteria might not be simple for them. You really can’t make any assumptions. Learned our lessons from the first patient, the second patient interaction went more smoothly. Patient preferred Luganda so we had an interpreter with us. There was one question asking about getting immunizations when our interpreter couldn’t find the correct word in Luganda because adult immunizations was not a thing in Uganda. People get childhood immunizations but there are no annual vaccines for adults. Overall, I love this process so much that we can apply our knowledge to improve patient’s understanding of antibiotics and prevent misuse. I am very excited to see our tools can be used in IDI after the pilot and help with global antibiotic resistance awareness.

The rounds we did with meningitis team, neurosurgery ward at Mulago and Nakasaro were also the best part. I never got bored because I almost had different things to see every week. I had the opportunity to learn about diseases and corresponding treatments that are rare in the US such as TB and malaria. Knowing how important it is to consider the most appropriate drug therapy in the local context with limited resources and medications. I still remember how shocked I was when I saw the management plan was so different from the US guidelines. Once I understood the reasonings behind it and more familiar with the situation that certain drugs or labs might not be available, everything seemed appropriate and the best option for the patient. I feel very fortunate to see the difference private and public hospitals and to know more about the health care system in Uganda. Meanwhile, I was comparing it with the health care system in the US and also in China, where I grew up from. We did a presentation on pharmaceutical care in the US to Ugandan pharmacy interns. We introduced and basics of pharmaceutical care process, how pharmacists’ role was evolving and expanding, what pharmacists can do in different settings in the US. We have a lot of question about how this care process is possible in a resource limited country when you recommend certain drug, but it may not be available, or it may not be possible for patients to keep appointment or certain equipment is not available for IV compounding. The situation right now is In Uganda, the pharmacist role just started shifting from dispensing to pharmaceutical care pharmacist work with health care team in the hospital. It reminds me that no pharmacist was working in the hospital in China 10 years ago, but now clinical pharmacy is developing very fast. It is very interesting throughout this rotation, I have been comparing what I have seen in different countries.

At last I have to mention that the Safari, Entebbe zoo visit, and Nile river rafting were awesome bonus to this rotation that I wasn’t expecting at all. This rotation is indeed an unique experience and I enjoyed it so much.

Preventing HIV Infection in Women

By Melanie Nicol

While the students are busy wrapping up their last week in Uganda, I thought I'd take this opportunity to talk more about my research. If I could describe my research in two words it would be "tissue pharmacology." I've already told you a bit about my project to understand drug penetration in the brain in the "Mushroom Meningitis of Uganda" post.. Now I'd like to aim a bit lower and talk about drug penetration in the genitals.

Global HIV statistics (UNAIDS and AMFAR)

My first research project as a graduate student was to develop a model using human vaginal tissue that could be used to evaluate drugs being considered for use in HIV prevention for women. Why focus on women? In the United States, women make up <25% of the people living with HIV. Globally, the statistics are quite different. The one that I always find the most sobering, HIV/AIDS is THE LEADING cause of death in women of reproductive age (ages 15-44). This statistic is largely driven by the epidemic in Sub-saharan Africa where young women are 2-3 times more likely to be infected than young men in the same age group.

Despite this, women are left with few effective options for prevention. Due to social structures and other barriers, women are seldom empowered to negotiate safe sex practices with their partners such as condom use. Pre-exposure prophylaxis, or PrEP, is the use of anti-HIV medications in people who are at high risk of getting HIV to protect themselves from infection. This is a similar concept to taking anti-malarial drugs prior to traveling to malaria-endemic countries. The approach has been shown to work for HIV as well although its far from optimized. A lot of questions remain. Which drugs should we use? How many drugs should we use? How long should they be used? Which populations should we target?

There is currently only one drug that's been shown to be effective as PrEP (although several more are still being studied). Truvada is a single pill that contains two different anti-HIV medications. Taking this drug once a day has been shown to be highly effective at preventing HIV acquisition. The World Health Organization as well as local governing agencies in many countries have endorsed the use of PrEP. However, not all studies of Truvada showed positive results. In fact, two of the major clinical trials done in African women found no reduction in infections in the group of women randomized to receive Truvada compared to those randomized to receive placebo. A lot of investigations have since tried to understand WHY these trials failed when others succeeded. The most obvious explanation is that adherence in these trials was low. Indeed, when random blood samples were tested, <30% of women had detectable concentrations of Truvada, suggesting most women were not taking the drug once daily as prescribed. Another explanation has emerged that is more complex-maybe the efficacy of this drug for HIV prevention is dependent on the site of exposure to HIV. Globally, the majority of HIV transmissions are through sexual transmission, heterosexual and homosexual.  But, not all mucosal surfaces are created equal. 

So, starting with that first project as a graduate student in 2009, I have spent the past (nearly 10) years researching how HIV drugs work in vaginal and cervical tissues. What I've learned: the female genital tract is a complex environment, and therefore interactions with drugs are equally complex. With 2nd year pharmacy student Joe Corbino, and UNC colleague Mackenzie Cottrell, we recently wrote a review on this topic that was just published this week.

Part of the MUJHU research team going through study supplies
(LtR) Betsy Kamira (study gynecologist), Esther Isingel 
(study coordinator), Samuel Kabwigu (study gynecologist), 
and Flavia Matovu (study site Principal Investigator)

In an effort to better understand this complex environment, specifically how this environment may affect the efficacy of PrEP medications, I am collaborating with Dr. Flavia Matovu of Makerere University and MUJHU Research. Dr. Matovu has an R01-funded research project where she is following a large number of women receiving Truvada (the drug used for PrEP). From this cohort, we recruited a small number (50) of subjects to provide additional sampling from the female genital tract. These samples (including biopsies and swabs) will be used to describe drug concentrations, characterize the vaginal microbiome, examine inflammatory status, and lastly test how these three things are related to each other. Additional patient factors, such as use of hormonal contraceptives, will also be looked at to see if this alters drug concentrations in genital tissue. This is an important consideration as women of reproductive age are one of the critical populations where HIV prevention options are sorely needed.

MUJHU Tower

Between November 2017 and April 2018, the MUJHU research team completed screening, enrollment, and sampling in all 50 women. (To give some perspective, I have an identical study here in Minnesota. We have been recruiting for a year now and 15 women have completed, highlighting the difference in the epidemic between Minnesota and Uganda.) The past few weeks, the local research team has been working to organize samples and prepare them for shipment. We've also been going through the data collected (quality control check) to ensure things haven't been missed. Soon the samples will be analyzed and we'll be able to start addressing our research questions. Very excited to see what we find! 

Rafting in Jinja

By Sara Brown

Le temps passe vite! Time flies. I was sure I would be homesick by now, but I have been too busy to miss home (sorry, Mom!). This was our final weekend in Uganda and it was full of excitement and terror. We went white water rafting down the Nile with the company Nile River Explorers (NRE). Two of our housemates at Welo Inn signed up so we tagged along for the ride. It was quite the experience. We signed up for the grade 5 full day trip, which covered 8 rapids over 3-4 hours. 

Saturday morning we met a shuttle bus near the Acacia Mall and went to the NRE base camp in Jinja. They provided a breakfast consisting of: watermelon, bananas, passion fruit, rolex, coffee, tea and water. They said, “If you’re going on a full day trip, eat up, you’ll need the energy.” This was an understatement. At base camp, we got fitted with life jackets and helmets, which I attached my GoPro to. We then got on another shuttle bus that brought us to the Nile. After a safety demonstration, we loaded 6 people into each boat to practice paddling, getting down onto our knees and pulling ourselves into the raft. Then the real adventure began.

The first set of rapids were too shallow to paddle through, so we portered halfway then went down. I screamed as a giant wall of water came over our raft (this was nothing in comparison to what was to come later). We flipped our raft on the second set. It is horrifying to watch the videos of being underwater! Our raft made it through the third set okay but we ended up “surfing” between two waves on the fourth rapid. We flipped on rapid number five and had to clamor quickly back into the raft to get prepared for the sixth set of rapids. Here, we got stuck on a rock shelf but thankfully made it down okay. In preparation for the second to last rapid, our guide said if we paddled the entire time, we wouldn’t flip. A chorus of “Paddle! Paddle! Paddle!” erupted and we succeeded. The eighth rapid was the longest. We flipped immediately. Half our passengers stayed with the raft and the other half got swept downstream. I was one of those downstream and it was quite enjoyable being in the water and riding the waves. Eventually, we reached shore. I was so thankful for dry land.

Nile River Explorers provided supper before we got onto buses and departed. It was a great day and I am so thankful I put my fears aside and went white water rafting!

On the road to recovery - the role of family and friends

By Prosperity Eneh

Since we have been in Uganda for the past weeks, we have continued to observe the healthcare system. One aspect of the healthcare system in a developing country like Uganda that is very much different from what I have experienced in U.S. health care is the role of family and friends  in care provision. In each hospital setting we have visited while here, family is everything to the patient. In the absence of family, chances of positive patient outcomes are greatly reduced. The family of the patient is so important that at Mulago Referral Hospital, patients with no family or friend with them receive a special yellow blanket wrapped around them to identify these patients. These patients are less likely to overcome the illness that brought them to the hospital.

Why is this so? Well your family is so vital to your recovery process here. With limited resources, there are limited amount of nursing care that can be provided. Each nurse is in charge of so many patients that they cannot provide intimate care for each one of them. The family fills this role. At least one family member of the patient or a friend essentially comes to live in the hospital with the patient. They bathe, change, clothe, buy needed medications and advocate for the patient. In some cases where professional healthcare provider shortage is more pronounced, the family member can even be taught aseptic techniques for changing IV bags for the patient. From a pharmacist's point of view, the family or friend the patient has with them can truly influence medication compliance while the patient is in the hospital. The family member usually determines which medicines the family can afford based on the doctor's prescription list, and the education level of this family member can be critical in ensuring that the patient takes the medication the right way as outlined by the doctor. One role of the pharmacist that we have observed here, especially in the government hospitals is education of family or friends to ensure appropriate medications are purchased and provided to the patient accordingly.

Economically speaking, the burden of healthcare can be very catastrophic for many families here. While the cost of healthcare may seem minimal when compared to the U.S. cost of healthcare, having a sick family member can wipe out savings for many family members. A one night stay in the ICU can be as high as 500,000 shillings (approximately $135) and this might not seem like a lot of money but it can take several months for many families to get this kind of money. Medications are often purchased in little doses, (3 days, 5 days, 7 days etc.) and not all that is on the list can be purchased at all times. Furthermore, the patient and another family member or friend have to stay in the hospital and hence they are both loosing potential income while in the hospital.

It is often difficult to truly understand from afar and when one is not in another person's shoe. As a pharmacist in this setting, it is hard to think only of guidelines and following a set of guidelines for practice. You have to consider so many other angles in helping the patient on their road to recovery. You have to consider patient's educational level, family involvement in care & social support, financial situation, likelihood of return to follow up, medication and lab supply issues etc. These all play a part in your clinical decisions and often times I find myself asking the physicians and pharmacist why they made one choice vs another and finding out that they had to consider all these aspects in making a decision. It is humbling to see this.

I am amazed by the resilience I have seen in many patients considering the situation. It also gives me hope to see the dedication from family and friends in care provision.

At UWEC

Eid (celebration of the end of Ramadan) was on Friday June 15th and this was a public holiday. We took it as a day off and travelled to Entebbe. We visited the Uganda Wildlife Conservation Education Centre (http://uwec.ug/). We got to see many animals including; giraffes, lions, leopards, cheetahs, hyenas, rhinos, chimps, shoebill stork, elephants, snakes, crocodiles and many more. There was also an option to go on a Carmel ride! We had a spectacular tour guide named Sam and he was quick with facts and interesting theories about the animals we saw. Sam was great! We then went to a Thai restaurant by Lake Victoria which was beautiful and later spent some time at the beach nearby. It was a great way to enter the last weekend for Sara and Kunkun.

Beach front - Lake Victoria

Not for the Faint Hearted

By Sara Brown

It’s hard to describe in words what I saw today. Especially without making people queasy…

Dr. Nicol is doing an autopsy research project. She is having tissues collected to have them analyzed for drug levels to determine penetration. Specifically, she is looking for medications used to treat HIV (antiretrovirals), Cryptococcal meningitis and tuberculosis in the brain, female reproductive tract and bodily organs. These drug concentrations will be analyzed for their potential use as pre-exposure prophylaxis (PrEP) to reduce the likelihood of contracting HIV. Dr Nicol talks more about this project in this previous post. Prosperity is also working with Dr. Nicol on this project and she was very excited this morning when she told us the news of the arriving cases.

Prosperity in her PPE 

Instead of going on ward rounds, Kunkun and I went to the Mulago hospital morgue to observe. It was quite the experience, to put it mildly. Prosperity was a champ; she got donned in personal protective equipment and went into the morgue first. Since it is a small building, we figured we would take turns and rotate through. While Prosperity was inside, Kunkun and I waited outside the building. This was the worst part for me. My imagination was running wild and I was expecting the worst. The anticipation was killing me. Finally, it was my turn to go in. I was taken aback by what I saw, but oddly enough, I eventually got used to it. I was so curious; I wanted to look at everything, but at the same time didn’t want to look at the bodies at all.  I wouldn’t say I was comfortable there (I will stick with pharmacy as a career) but I didn’t vomit or get nauseous. I was impressed by the pathologists’ work. The bodies were well-taken care of: the cuts were clean and precise, and the stitches were phenomenal.

Thumbs up

Once I first got into the morgue, I slowly walked around and observed. A pathologist quizzed me on an organ he was holding: it was a spleen, not a kidney (anatomy was a long time ago--I will stick to pharmacy). He then asked me what the black spots on it were. I said cancer. Wrong. He said it was disseminated tuberculosis. After 10 minutes of observing pathologist, I turned to Paul, the research assistant part of Dr. Nicol's study. He and Prosperity were in charge of ensuring the tissues were collected and labeled correctly according to the protocol. It was a tedious and time-consuming process; we were there for a total of 4-5 hours. Around noon, we were shocked that we were hungry, despite being surrounded by appetite-suppressing views.We were thoroughly exhausted and starving. I wanted nothing but a shower.

Couldn’t rest yet, though: next step was to bring the samples to the lab for storage. We learned some things during the procedure that may improve the collection process. Kunkun and I will help Prosperity write a best practice procedure for collecting samples.  

The pathologist, me and Paul after we were done

We left the lab in search of food. We must’ve looked terrible because a security guard herded us directly to the door of the Good Samaritan food joint we were trying to find. I shook his hand in gratitude. We wolfed down a plate of rice, beans, spinach, skewered goat meat, YAMS (they call them sweet potatoes here, but they are indeed yams—there’s a difference, look it up), beef and coleslaw. I chugged 2 liters of water. We then trudged up the hill back to our respective beds, still thoroughly exhausted.

Being in a morgue in Uganda was a once in a lifetime experience that I will never forget (I can’t forget because these images are burned into my memory...). As with everything else on this APPE, I am so grateful for this unique opportunity to learn about healthcare in an underserved region. I will definitely be sticking to my pharmacy career, though—I made the right choice.

Time flies! How do we slow it down?

By Prosperity and Kunkun

Weekend Adventures - By Prosperity Eneh

Our time in Uganda has indeed moved so quickly with all the learning, excitement and other activities packed in our days.

This past weekend we decided we needed to take it a bit slower and have a rest day on Saturday. Sunday was more active with a 1 hour trip to Entebbe. It feels like Entebbe and Kampala are like Minneapolis-St Paul. The international airport is in Entebbe and that is also home to some of Uganda's beaches. We drove out to Imperial Beach and Resort Hotel in Entebbe and this resort has its own beach front that is quite interesting to be a part of. There was music and dancing and a beautiful view of Lake Victoria. We mostly people watched, enjoyed a close view of the huge birds that came down there and also got some time in the sun! At the end we went to a craft market close by the Victoria mall. Dinner was at Cafe Javas Entebbe and then back to Kampala. It was a nice and relaxing weekend and a great way to recharge for the upcoming week.

Enjoy some pictures from our Sunday activities;

At Lake Victoria L>R Sara, Kunkun, Prosperity

Front entrance of the beach area for Imperial Resort

Imperial Hotel Beach 

Lake Victoria

Bird Watching

Sara at the craft market

Kunkun at craft Market 

Start of a new week - By Kunkun Wang

It is hard to believe Sara and I head out of Uganda in less than 10 days! This week I am going to Kirrudu General Hospital with Prosperity and the rest of the Crypotoccocal meningitis team. Sara is going to be at the Neurosurgery department in Mulago Hospital with Winnie - the Ugandan Pharmacist. 

This morning (6/11/18), the IDI Cryptococcal meningitis team had their research meeting and it was very interesting. This was my first time seeing how research protocols are developed. The team is made up of physicians, nurses and pharmacist from Uganda, Minnesota and the UK. 

After the morning research meeting (which we found out happens every Monday) we head out to Kirrudu. Most of the patients we see at Kirrudu are ones diagnosed with meningitis. However, today one of the patients family member presented with symptoms of hyperthyroidism that we noticed. I was able to look up causes, symptoms and treatment of thyroid problems. Prosperity and I also provided recommendations on renal adjustments of medications for other patients during rounds. 

We had dinner with some friends at an Indian restaurant called Biryani House. We were welcoming back Bridget who had been away for sometime in South Africa and saying farewell to Frietz who is heading back to Minnesota. I ordered my third Mango Lassi. I liked the first one that I ordered in a non-indian restaurant best...I think I will stop ordering mango lassi here because I realized that the problem is Uganda mangoes just taste different that China's mangoes.. the pineapples and passion fruit are the best here!

I have already started missing Uganda at this point even though I am still here.

Back to Minnesota for Dr. Nicol

By Melanie Nicol

My time in Kampala for now has come to an end, with 16 days in country this trip. I'm not sure I've found the ideal length of time for a productive trip. My shortest visit has been 4 days (passport issues....long story) which is not near enough time to get over the jet lag, and my longest 21 days. I have an active research lab back in the States, as well as students and other mentees so it is difficult to be away longer than 3 weeks. Plus I have this one waiting at home for me.

My 13 year-old terrier mix Sadie

I may be leaving Kampala but the work in Uganda continues. I know I will be leaving the students in capable hands with pharmacists Prosperity and Winnie here. This endeavor would not have been possible without their help and I truly think we have created a valuable variety of experiences for the students. I went into academia because nothing excites me more than introducing someone to new experiences or ideas. Nothing means more to me than being able to share my opportunities and experiences in Uganda with the students.  Thanks to video conferencing with Skype and Google Hangouts, I will be able to frequently stay in touch.We already have several meetings and discussions planned over the next two weeks while the students complete their rotation.

The staff at We'lo Inn were very gracious hosts.

The research continues as well. Although I haven't yet been able to share on this blog all of the projects I am involved with, I was able to touch base with all of my collaborators this trip and discuss ongoing projects as well as those in development. One of the challenges of doing international research is not being physically present. The key is to have strong collaborations and invested people on the ground to keep the projects moving forward. I try to make it to Uganda at least twice a year- I think this is important because it shows my collaborators that I am also invested and committed to these projects. I am thankful that technology today means it is easy to stay in touch. 

There were some new things for me this trip. This was my first time visiting the Gadaffi Mosque, the Uganda Museum, and Murchison Falls. I tried a rolex for the first time. I learned Pepto Bismol chewables are >>> the liquid (as a pharmacist it probably shouldn't have taken my six trips here to realize that). I learned some new Ugandan phrases like "American height" (apparently a coveted trait). Lastly, despite being involved with the meningitis research team for some time, I learned more about treatment and care of meningitis patients in these 2 weeks than the previous 2 years.

Continuing Professional Development and the City of Kampala

By Prosperity Eneh

Intern CPD
Thursday morning (6/7/16) started out early as we headed to the Continuing Professional Development (CPD) pharmacy intern meeting at the Makerere College of Health Sciences. Only problem is that we ended up in the wrong room to start off..

Waiting in the wrong room (oops!)

Thankfully we had the Intern President to help direct us to the right room for this meeting! Pharmacy interns in Uganda are scattered all over various hospitals and medical centers in the country. The internship year is a mandatory part of being a pharmacist in Uganda and students are eligible to complete this one year program after they have finished their 4 year pharmacy degree (Bachelors in pharmacy program). The CPD meeting is set up to educate the interns on a range of clinical information and the topic of discussion today was Pulmonary Tuberculosis (TB). The presentation was delivered by Patrick Opio who is a pharmacist that works for Mulago National Referral Hospital (currently in Kirrudu General Hospital). This was a great topic for us to learn about given the prevalence of Pulmonary TB in Uganda and in the patient population we will continue to work with while here. After his presentation, he encouraged the interns to continue to stay involved in research and clinical work. He made two statements that I would love to highlight - "the patient's care team is not complete without the pharmacist" and "get involved with research when you are able to". From these statements, it is great to see that in Uganda as well, the pharmacy profession is working to be further integrated into the patient's care team and be able to contribute the unique knowledge that we possess based on our training, for improved patient outcomes.

CPD attendees for today

City of Kampala

Caramel Cafe and Lounge

Getty image of the City of Kampala

As Dr. Nicol departs today, we decided to have a goodbye lunch at a new restaurant that opened at the Acacia Mall. We all enjoyed the meal and some of us had some pastries as well. The ambience of the place and the contrast to some other parts of the city made me think of talking about our environment in this post. Kampala is like many world cities with a wide range of socioeconomic classes represented. We have visited many upscale restaurants like the one where we had lunch today called Caramel Cafe & Lounge (pictured) and there are also many other places like the big shopping malls/centers, extensive office building and very nice apartments/hotels in downtown Kampala. It is also however not very uncommon to find things that are unique to poorer cities like street hawking and unfinished or bad roads in the city of Kampala.  Pictured below is our Uber driver from today (yes we use Uber a lot!) purchasing a clothing item from one of the street hawkers that walk alongside traffic jams. That being said, Kampala is such a vibrant city and there continues to be growth and development.

Today's Uber Driver making a purchase 

Halfway Point--going fast!

By Sara Brown

I have been in the ICU’s and in the general ward at Nakasero hospital this past week with Prosperity. There is a 4 bed ICU for critically ill patients who require intensive monitoring. The step-down unit is called the HDU, which also holds 4 patients. These are some of the cases we encountered while rounding in the ICU’s: CNS lymphoma, gunshot wound, severe dehydration, hypertensive emergency, DVT’s in a thrombocytopenic patient, among other interesting cases. 

The general ward also had interesting cases: refractory hypertension, newly diagnosed Type 1 diabetes, DVT’s, S. aureus hip abscess, kidney stones, severe itching from intrathecal morphine and more. This floor was interesting because the care was managed between a medical officer who saw everyone and a primary specialist. I crafted an information sheet with 2 options for initiating insulin therapy, so the general doctor could discuss changing the insulin dosing frequency with the specialist. It got placed in the patient’s chart!

Upon reflection, I realized that pharmacists are situated perfectly to ensure patient care while on rounds. We helped bridge communication gaps between different doctors and created discussions about patient’s therapy. We rounded with very receptive physicians who took our recommendations on drug dosing, renal adjustment dosing and discontinuation/initiation/adjustment of therapy.

It was fun looking up the different drugs we do not have in the US and comparing treatment strategies. Oftentimes, a medication cocktail was prescribed instead of maximizing the dose of one drug before adding on another. This difference may have to do with limited follow-up care after discharge. In the US, a patient will get plugged into a clinic and go for regular blood pressure checks until a therapeutic dose is achieved. Here, I’m not entirely sure what happens. I will have to ask a medical officer tomorrow!

And a food update: I ate West-African food yesterday twice (!) from the restaurant Mama Ashanti. It was very good! Fried plantains are becoming my favorite snack. I will for sure attempt to make them when I get back to the US 😊 Prosperity highly recommends getting plantain chips from Trader Joe's, too. 

Tonight, we had a farewell dinner to Dr. Nicol, who is going back to Minnesota tomorrow. The Welo Inn staff prepared a ton of traditional Ugandan food to feed 15 people! They had: matoke, boiled sweet potatoes, fried yellow potatoes, chicken, beef, peanut sauce, cooked greens, beans and rice. It was delicious! Following dinner, we had a dance party so people could dance to music belonging to their country/region/state. Crazy to think I'll be going back to the US in about 2 more weeks! Time sure does fly. 

Kunkun's first day at Kiruddu

By Kunkun Wang

Today was my first day at Kiruddu, one of the public hospitals in Kampala. It is government funded and free of charge for patients. However, sadly they usually run out of certain medications so the family has to go to outside pharmacy to buy it. Currently they run out of lab supplies too so patients need to go to private labs to get their lab checked. Comparing with the IDI clinic when most patient there are stable, patients here are having more severe problems.

I rounded with the team and watched a lumbar puncture for my first time. Everything here is very different than the hospital in the US because of limited resources. I also feel that because TB and malaria are so rare in the US, I haven't learned as much on those topics...I am looking forward for more days at Kiruddu and learning more.

My final thought is I really hope the rain can stop tomorrow so my laundries can dry.... Still can't believe it's always around 70 in Kampala where it is so close to the equator.

"There is far too much to take in here"- Safari Adventures

By Melanie Nicol

The rest of the group is probably annoyed by the number of Lion King references I made this weekend but I can't seem to help it. The "Circle of Life" was on constant repeat in my head during the game drive..even our ranger guide said "there's a pumbaa" when we saw our first warthog.

Boat cruise down the Nile River

The weekend started at 6:15 am on Saturday morning. Our guide Arthur from Econest Tim Tours picked us up from the Inn and we began the drive to Murchison Falls.  Murchison Falls National Park is the biggest national park in Uganda at 3840 square kilometers (that's about 1480 square miles; bigger than Rhode Island but  ~half the size of Yellowstone National Park).  It took about 4 hours to get to the edge of the park, and then we drove another hour until we reached the Nile River where we had lunch. At 2pm we started a boat ride down the Nile. During our 2 hour boat ride we saw elephants, giraffes, lots of hippos, crocodiles, and some interesting birds. When we reached Murchison Falls, about half of those on the boat turned around to go back but our group was brave enough to make the 1.5 hour hike to the top of the falls. The hike was not especially difficult although it was steep and a good part of it directly in the sun. It was well worth it though as we were treated to many special and unique views of Murchison Falls as well as the "upper falls" otherwise known as "Freedom Falls" that can only be seen from the hiking trail. Standing at the top of the falls and looking down the River Nile was a highlight of the trip, a favorite of both mine and the students.

Freedom Falls on the left and Murchison Falls on the right. The upper falls were created by massive flooding in 1962, the same year Uganda became an independent country, hence the name "Freedom Falls"

At the top of Murchison Falls

Because our boat ride went longer than expected, we missed the 6pm ferry and had to wait a bit for the last (7pm) ferry to take us across the Nile to our lodge. During the drive from the ferry crossing to our lodge, we met what Arthur called a "lonely" elephant who seemed determined to not let us pass. I learned just how quickly a safari van can do a K-turn on a narrow road. We finally arrived at Pakuba Safari Lodge at around 8pm. Some quick showers, dinner at the buffet...most of us were in a dead sleep by 9:30 pm.

Sunday morning started with breakfast at 6am. By 6:30, we were back in the safari van, now with our ranger guide Sam, to begin the game drive. We quickly saw many elephants (these were all more friendly than the one we had seen the night before- they mostly ignored our presence), giraffes, hartebeest, Ugandan cob, water-backs, pumbaas...ahem...I mean warthogs. Despite our early morning drive, we were unfortunately unable to find the lions. The lions can be the most difficult to find- they do much of their hunting under the moonlight and are quite content to sleep (sometimes in the trees) during the day. We drove throughout the park for over 4 hours, to all their favorite spots (according to Ranger Sam) but were unsuccessful. Guess next time we need to verify our appointment with the lions!

Water Buffalo- The only time Lion King music was not in my head was when it was replaced by the Veggie Tales "Everybody has a Water Buffalo"

Jackson's hartebeest- According to our guide these animals are "quite dumb". When being chased by a lion, they sometimes "forget" what they are running from and simply stop. Despite this apparent evolutionary disadvantage, this species seemed very plentiful within the park.

We then began the long journey home. By now we had driven far into the park so the drive home felt even longer. We drove ~ 2.5 hours, stopped for lunch, then drove ~3 hours back. We returned ~ 6:30 pm...so other than the stop for lunch we had been sitting in that safari van for 12 hours!  We packed a lot in a 36 hour trip. To save time and money, we did in 2 days what most people will do in 3. There really is far too much to take in here. More to see than can ever be seen.

A few things to wrap up the week

By Prosperity Eneh

TGIF. Happy Friday from Kampala. Since it was the end of the week, some of the staff at the general ward at Nakasero hospital where Kunkun and I have been working the past week were easily convinced to take a fun picture for our blog. We have been fortunate to participate in patient rounds and converse on unique differences in patient management strategies with this amazing team this past week. We also interacted with many healthcare professionals that are not pictured below.

From left to right; Esther (Pharmacist),Liz (Floor Manager), Becky (Nurse),Kunkun,Prosperity and Lucious (Nurse)

Here are a few things that peaked my interest and I thought I would share today to wrap up the week;

>> Something that is quite different here in Uganda compared to the U.S. is cost transparency with healthcare services. Since most of the population served in hospitals in Uganda are not  covered under insurance, there is need for transparency with cost so that patients can anticipate what they would have to pay in cash for the services provided. Pictured below is one of such notices to patients. In the U.S. we often do not have a sense of what the "real" cost of healthcare services are. Increasing price transparency to an extent is something that I personally think can help with the ever increasing cost of care in the U.S. If more people knew how much procedures really cost, then there might be an incentive for more rational use of healthcare services, but hey that is just a hypothesis and no way of knowing if it would make any difference.

Prices for various services inpatient

>>The British National formulary came in super handy! As we were working in the ward today, a case came up that involved medications that we do not use in the U.S. So we consulted the British National formulary for guidelines and recommended dosing. It turns out this guide is used often by the medical officers here at Nakasero in addition to the Uganda Standard Treatment Guidelines.

BNF

>> Use of paper patient charts. In the past, I would often complain when I found it hard to locate things on EPIC (an electronic medical system used in many U.S. Health-systems), even when there was a Ctrl-F option. Not having Ctrl-F for paper patient charts really made me appreciate EPIC more. Paper charts as pictured below are used for documenting patient course while in hospital. It is organized by admit information, labs, doctor notes, nursing notes, billing etc. Once patient is discharged from the hospital, the chart is taken to records. I was not able to find out if the same chart is located if the same patient comes back or if another record is created but I will ask about this next week. There is obviously some convenience with electronic medical records but to implement that in this setting will require introduction of computers to students in early ages in school. Merely installing computers and expecting hospital staff to use it would not be the right approach according to my discussion with one of the leadership staff. Doing this would actually hurt patient care and take a longer time for care provision and documentation given the level of comfort of staff with using computers/typing information into such a system. A more country-wide approach of introducing computers and typing lessons at a young age would lead to a generation that is comfortable with use of computers for any future work opportunities. This was definitely an intriguing conversation and I am glad it happened.

Cart with paper charts

So we ended the day at the Uganda hub in MUJHU where Sara and Kunkun gave case presentations for a case they picked out for this week. We also made final plans for our trip to Murchison Falls for the weekend. Be on the look out for our Safari Adventures.. Woohoo!