Anniversaries and Milestones

By Melanie Nicol

And that's a wrap on the 2019 Uganda APPE!  Everyone made it back safely to the U.S. and students have already settled into their next rotations. This was my third offering of this APPE. Every year I've learned so much. Since it's a research elective, I have a lot of flexibility in how I implement the rotation. Therefore I've been given the room to try some creative projects.

With Winnie Nambatya, one of the fantastic Ugandan preceptors
we worked with this month.
Front: An and Melanie M
Back: Joe, Melanie N, Winnie

In the hope that there may be some other APPE preceptors of research electives looking for some ideas, I wanted to share one new assignment I tried this year that worked fantastically well. Each of the students were given a topic. These topics had been chosen based on conversations I've had with Ugandan practitioners and researchers as being related to some sort of ongoing or anticipated problem or unmet need in Uganda. Here are the examples from this year:
          1) Is there a role for pharmacogenomics in Sub-Saharan Africa to improve patient care.
          2) With the rollout of dolutegravir in Uganda, what is known about incidence of dolutegravir-related IRIS
          3) As availability of flucytosine in Uganda may increase in future, is there a role for therapeutic drug monitoring of antifungals in resource-limited settings.

Students were asked to do a literature review on their topic. Based on what they found in the literature, coupled with observations from their experiences in different settings throughout their rotations, they were to design a research study to address the research question they were assigned. In addition to sharing their results in a presentation at the end of the rotation, they were asked to prepare a specific aims statement.

I didn't know how well this was going to work but the students hit this assignment out of the park. All three of them proposed studies that I think have potential to be implemented.  In pharmacy school, students learn how to critique research studies. But how to identify a research problem, and then design a study to address that research problem requires an entire different level of thinking that most people (including myself) don't develop until years of training in graduate and post-graduate programs. Likewise,writing specific aims page can be a daunting task. They are only one page in length but they require precise writing and an impeccable flow of logic- they are intended to convince a grant reviewer or funder that your study adequately addresses a significant problem. Writing a compelling specific aims page is an invaluable skill as a researcher. In short, feedback from the students suggests that both myself and the students got a lot out of it. The students shared that the project forced them to think in a way that they weren't used to thinking. Mission Accomplished!

So now I turn my thought to next year of the APPE. Since Prosperity has graduated and I will no longer have her help in precepting this rotation,  I have been thinking a lot about timing and capacity. Over the next few months, I'll be thinking a lot about: What is optimal timing of the rotation; What is the optimal number of students? What is the right balance between clinical and research activities? How can I better integrate research projects into the rotation?

In other news, my career is approaching a significant milestone. Just last week I submitted (what I hope is) the final draft of my dossier for promotion and tenure. Over the next year, various levels (External Peers, Department, College, Provost, Board of Regents) will be reviewing this package to determine whether I meet the requirements for tenure at my University. Preparing this dossier has taken a significant amount of energy and attention from me, not only in putting the document together, but moreso in ensuring that I had the publications, grants, and evidence of quality teaching and service to include in the document. Needless to say, I am very much looking forward to an upcoming weeklong vacation I will be spending with my family in Ohio.

While preparing the dossier, I spent a lot of time reflecting on my past contributions. The entire point of the dossier is to explain your scholarship and why it's important. This summer, my goal is to re-shift my focus to be forward-thinking again. Although there are lots of data to collect and papers to write from our current projects, I've already started planning my next grant applications. It's exciting and exhausting to get back into grant writing!

While this summer/fall there are grants I am working on (an internal grant, an R03, and a co-I on a P01), I have also started planning for my first R01! For those of you not in research/academia, R01s are the quintessential backbone of NIH research funding. I'm not exaggerating when I say it will take me 6 months - 1 year to write this. My task for this fall is to nail down my specific aims (see above). I've been reflecting recently about how my different lines of research may fit together into one grant application. How can I leverage my partnerships in Uganda? What new collaborations should I be pursuing? What preliminary data do I still need to obtain to make this application competitive. I don't know these answers, but I'm excited to dig in this summer. More later!

Uganda has a lot going for it...but I miss this face when I'm away..
Happy Adoption Anniversary Sadie!

The "other Melanie's" final reflection

Post by Melanie Mahoney, PD4

That’s a wrap! Today marks our very last day in Uganda. This experience has taught me so much in so many ways. I have grown and become more confident in my clinical knowledge through rounding with different pharmacists, medical officers, and specialists. I have developed my presentation skills with a journal club, case presentation, and final project presentation. I have expanded my knowledge and understanding of research through interactions with the cryptococcal meningitis research team and development of my own research project proposal. My personal project focused on flucytosine therapeutic drug monitoring in the treatment of cryptococcal meningitis.

Beyond all the official, structured learning, I also think this was a time of personal growth for me. Leaving for Uganda I was a bit nervous about being so far away from my husband, family, and friends for 5 weeks. I love to travel but this was a different kind of trip that I knew would challenge me. I was really surprised that I never got homesick. I appreciated the opportunity to completely immerse myself in my learning here and set everything else aside for a few weeks. While the past few years of pharmacy school have been rewarding, this time has also been very stressful and overwhelming. I tend to “say yes” to everything and sometimes over-involve myself in work, volunteering, training, and other activities. The past five weeks have allowed me to “reset” and mentally prepare for my professional future. I have seen how productive I can be when I am fully committed to one experience.

I have also loved learning and hanging out with my classmates on this trip. It has been really helpful to share this experience with such wonderful people who are also passionate about global health and willing to discuss and reflect on our learning together. We have also been fortunate enough to share in some fun excursions from the safari at Murchison Falls to white water rafting on the Nile to countless trips to Acacia Mall for ice cream! After spending almost every waking moment with Joe and An, I’m sure I will miss them when we get back to the US and go on to different rotations.

Delicious gelato from Acacia Mall

I want to thank all the pharmacists, pharmacy technicians, medical officers, specialists, and students who taught us so much over the past five weeks. I know we all appreciate you taking the time to engage in our learning by asking us questions, describing patient cases, and patiently explaining the reasons behind certain differences in healthcare practice. As I wrap up my final thoughts on this experience, I am moved by how my perceptions of healthcare, and especially healthcare in a resource limited setting, have changed. I really loved exploring the differences between healthcare in the US and Uganda and learning why certain things are done the way they are here. I was surprised to see families bring in their own sheets for the hospital beds and help in caring for their loved one by preparing food at the bedside and cleaning out catheter bags. We learned about cultural differences and the shortage of healthcare professionals that cause family to be so involved in care. I was shocked to learn that most pharmacists are only at their pharmacies for fewer than ten hours per week and that pharmacy technicians are usually the ones checking prescriptions and providing patient education. We learned that pharmacy technicians actually have an advanced level of education in Uganda that prepares them for work similar to a community pharmacist in the United States. If I could bring one message back to share with others it would be that it is so important to seek understanding before seeking a solution based on preconceived expectations. This applies not only to experiences abroad but also within the United States. The US is a country of such vast diversity that it’s important to realize how our unique experiences can lead to different viewpoints and that this can become emphasized and more important to accept and understand in a stressful healthcare setting.

This experience has been so impactful for my professional development. This rotation has allowed me to learn more about infectious diseases and global health, two of my major areas of interest in pharmacy. I am looking forward to applying to residency programs this fall and will hopefully find a position where I can then move on to a second year infectious disease residency. In the end, I want to work in a setting where I can use infectious disease knowledge and my passion for continuously learning and public health to improve patients’ lives.

 

Melanie, An, and Joe on the
Nile River Boat Tour

Melanie, Joe, and An White Water Rafting

An's Final Reflection

Post by An Le, PD4

I still can’t believe 5 weeks in Uganda is almost over. Everyday, I am thankful for having this incredible learning opportunity to kick-off my last year of pharmacy school.

Looking back to our rotations at the Infectious Disease Institute, Nakasero Hospital, Kirrudu Hospital, and community pharmacy, the entire experience provided me different activities to apply and gain more research and clinical knowledge. At the beginning of the rotation, one of the most challenging parts for me was to have a better understanding of the pharmacists’ roles in Uganda. However, through our visits and conversations with different health professionals, we started to recognize the similarities and differences of the health system and the roles of pharmacists between Uganda and the United States. The main difference in the pharmacists’ roles is the majority of pharmacists in Uganda tends to be more involved in the supervising role instead of directly interacting with patients. I would also want to say that the hospitality of the health professionals in Uganda contributed to our positive experience. At each institution, the health professionals were so willing to teach us how care is provided here in Uganda, yet, they were also very eager to learn about the U.S. health system.

To wrap up this rotation, I got to spend the last couple days at the Neurology unit with patients who have traumatic brain injury and other brain-related conditions. Here, I got to work along side with a pharmacist, Winnie, who has worked so hard to let other health professionals understand the roles of pharmacists in clinical pharmacy. Following her was such a rewarding experience, as she taught me so much on how to approach each patient case and how to work effectively with the care team. She always made sure that I learned something new while being with her. We had a small debrief at the end of the day, so we could go over the important points we saw during rounds. These conversations were very helpful, as they helped me solidify the acquired information during rounds.

Throughout my time in Uganda, a couple things that surprised me the most is the numbers of research studies being conducted and the motivation of using evidence-based resources and recommendations in spite of being in the resource-limited settings. During one of my conversations with Winnie, my assumption about the practice completely changed when she told another Ugandan pharmacy student that pharmacists in Uganda have to use research literature as evidence when making recommendations to other health professionals. When I reviewed the literature for my proposed project on pharmacogenomics in sub-Saharan Africa, I was amazed by the number of initiatives and projects that have been invested in genomic studies.

An, Melanie, and Joe present to pharmacy staff at Nakasero Hospital

Joe, Melanie, and I also had an opportunity to give a presentation on minimizing dispensing errors and proper handling, storage, and dispensing of hazardous medications to the pharmacy staff at Nakasero Hospital. While preparing for this presentation, I realized that we started becoming more aware of the cultural settings to ensure the presented information is appropriate and beneficial for the staff at the hospital.  We talked about what the hazardous medications the hospital currently has on the formulary and other work flow at the pharmacy, so that we could select the information that would be applicable.

View from Speke Resort

Through our journal club presentations, case presentations, and literature review for our final project, this rotation really helped me improve my research skills and understand what it takes to successfully work in research field. Prosperity once told me that “Research is always connected to each other. You have to look at other studies to understand what other questions that still need to be answered”. Indeed, there are still a lot of research questions out there that need to be answered to improve patient care and treatment outcomes. I’m hoping that one day I will get to work in a position where I can combine both research and clinical aspect, so I can provide patient care from a different perspective. I believe the clinical knowledge will help me understand what research questions need to be answered to promote better health outcomes.

I will definitely miss the hospitality of the Ugandans, the beauty of the Ugandan wildlife, the wonderful matooke, and the completely different timing schedule. I’m hoping that one day, I’ll get to come back to this country and work along side with other professionals within the research area to improve patients’ health services and treatment outcomes.

Joe's Final Reflection

Post by Joe Corbino, PD4

            It’s hard to believe that I only have two nights left in Kampala before I begin the journey back to Minnesota for the remainder of my APPE rotations. These past four weeks have been full of exciting new experiences that both humbled and challenged me mentally, emotionally and physically.

            Over the past several days I have been able to conclude my clinical experience by attending a variety of rounds at Nakasero Hospital. As both An and Melanie have mentioned previously, Nakasero is a private hospital that resembles what we see in America much more than average healthcare throughout Uganda. I have been surprised by the shear number of malaria cases involving individuals from foreign countries. This reiterates a very important point, always remember to take your daily prophylaxis while in an endemic area! It has also been interesting to see the types of bacterial infections that have infected individuals in the intensive care unit. During my time three individuals developed blood infections with a bacterium named Acinetobacter baumannii, which was resistant to about every antibiotic available in the hospital. As medical professionals, especially future pharmacists interested in infectious diseases, we were worried about what that meant for antibiotic resistant infections in the near future! Nakasero has also given me the opportunity to converse with a variety of healthcare specialists, such as a cardiologist, nephrologist, and geriatrician. Both the clinical and personal conversations with these individuals has led me to have a greater appreciation for the compassionate care that they give to patients and the passion they have for their careers.

            Our final Saturday was spent relaxing at Speke Resort on the edge of Lake Victoria. Even with the overcast sky for most of the late morning and early afternoon, we enjoyed an Olympic size swimming pool mostly to ourselves in what felt like a totally different part of the world. The sun finally decided to come out in the late afternoon, which made a walk on the shores of Lake Victoria a perfect end to a lazy day. An added bonus to remember this great day was that we all are currently sporting some major sun burns.

An, Joe, and Melanie at Lake Victoria

            Due to this being a rotation with research emphasis, we were all assigned the task  to perform a literature review and design a research study on a particular topic. My topic was investigating the effect of an antiretroviral drug, dolutegravir, and the consequences it may pose to individuals initiating treatment during various stages of HIV/AIDS. If this is something that sounds interesting to you, I would be more than happy to talk your ear off as it is all I have been reading about for the past four weeks. Our final presentations were given this afternoon and we all feel a huge weight lifted off our shoulders!

            I feel extremely fortunate that the University of Minnesota has connections here in Uganda. The plethora of clinical and research activities that I have been able to witness firsthand have truly been life changing. I feel that my experiences over the past five weeks will impact my career for the rest of my life. I learned to have greater appreciation for all of the resources that we have available to use in America, not just medical. All of the institutions I have been immersed in have been able to provide comprehensive care even with limited resources.

            I am still surprised with how quickly I became comfortable in Uganda. I was expecting there to be an adjustment period where I would feel like a complete outsider. With the help of both individuals at the Minnesota House and healthcare professionals, I was able to quickly overcome any uncertainties about my place in this country. With only a few days left I am not ready to leave. I still find myself constantly surprised by the circumstances that people find themselves dealing with. Even with so little they find ways to live their lives to the fullest while rarely complaining. If anything, this is the lesson that I want to share with people when I return. We need to appreciate what we have in front of us and try to make the most out of it rather than wishing for more.

           

Kampala neighborhood

This rotation has constantly been making me question where my future in pharmacy is headed. I entered the rotation set on completing two years of residency specializing in infectious diseases and becoming a practitioner. Two weeks into the rotation I realized how much I enjoyed the process of research and thought that pursuing a PhD or fellowship may be a better option. Over the past few days my thoughts have changed once again! I have now even began to consider the possibility of completing additional public health degrees and working at a more global level to impact as many lives as possible through policy, research and public health campaigns. The bottom line is that this rotation has made me appreciate that there is so much more to healthcare than what I have been exposed to in the United States. I have a passion for improving the lives of people, especially thus suffering from infectious disease such as HIV/AIDS. I am more confident than ever that this passion and drive will allow me to find careers that work best for me in the future.

Lake Victoria

            We have several activities planned over our final two days, which is sure to make the time pass at lighting speed. With a presentation scheduled for early Wednesday morning and a last-minute info sheet added to our schedule the learning never ends! I look forward to the moments of reflection over the next several days and weeks. Thank you to everyone that has been following my journey in Uganda for the past month as it has been truly life changing.

Cheers to the Weekend!

Post by Prosperity Eneh, PharmD, MS

It’s hard to believe that I have been in Uganda for 2 weeks! Time has moved very fast with all the activities we have been engaged in. As this is my second time around in Uganda, I was happy to reconnect with some friends I made last year and also some of the health care providers I worked with as well. 

Working with the 4th year students on their clinical and research activities over the past 2 weeks has been very rewarding. Some of our plans have been modified as far as clinical activities but overall we have been plugged into the four main areas already discussed in previous blogs; Kirrudu National Hospital, Infectious Disease Institute, Neurosurgery ward at Mulago National Hospital and Nakasero Hospital. It has been educational and humbling to debrief after each clinical day and discuss the patients and cases that were most interesting, keeping in mind specific cultural context in making comparisons to US practices.

View of Lake Kyaninga from Craker lake home

This weekend we are taking it easy with fun plans. I made a trip to Fort Portal which is about 5 hours away from the capital city. I travelled with a few of the other Minnesota housemates. We stayed at a place called the Crater Lake home with amazing views of Lake Kyaninga. The home we stayed at is owned by a physician that lives in London currently but worked in Uganda for over 20 years. We booked the lake home using Airbnb and this is not so uncommon for expats to have homes in remote regions of Uganda and then put in up for rent when they are not in town. We had a lovely stay!  

Speke Resort

An, Melanie and Joe stayed in Kampala over the weekend to visit a resort center where they can work on their research projects if needed or engage in other fun activities like swimming! As this is our last weekend here, a trip to the craft market to purchase gifts for family and friends is also needed. 

As we wrap up the upcoming week, the students will be presenting on the literature review they conducted as part of the research project that they have been working on since they got here. As this elective APPE has a major research component to it, we have made a conscious effort to ensure there is adequate time allocated to both clinical activities and research activities. Each of the student already did a patient case presentation with a topic discussion and this week they will each present on the outcomes of their literature review. A specific aims document that describes a plan for conducting adequate research on the selected topic is also requested for each project. 

Personally, being a part of this rotation the first time and now for a second time has been such an amazing experience. I am so grateful for the opportunity and I hope that wherever my career takes me in the future, I will be able to start or continue a program like this. When I visit the wards and I see some of the providers I worked with in the past year and they recognize me and welcome me again this year, it makes me happy to know that a longer lasting relationship is being formed. Many of the Ugandan providers have been eager to teach and dialogue with us and this encourages an environment where there is mutual benefits to these trips we make. 

We are still staying cautious with the recent news of Ebola cases confirmed in Uganda. Activities in Kampala are going on as usual but in the area where the cases were confirmed, all the organizations involved are keeping watch and doing what is needed to contain the situation. I am also hoping to shed more light on the crisis in Congo which shares a border with Uganda. Per the last meeting of the WHO on Friday, it is still not considered a global emergency, however much is still needed to curb the spread of the virus. 

Again, it is hard to believe we have only 3 full days left in Uganda. In the upcoming blog posts by Melanie, An and Joe, they will be reflecting on their time here. Be on the look out for their wrap up posts!

Mweraba! (Goodbye in Luganda)

Contemporary issues in Kampala

The pharmacist Richard shows An, Melanie,
and Joe around First Pharmacy

Post by Melanie Mahoney, PD4

What a week full of learning! On Monday, I went to Nakasero Hospital with Prosperity, and got to round with two physicians in the ICU and HDU (high dependency unit). We were lucky enough to spend our morning with two great physicians who were very happy to have us there and went above and beyond to involve us with questions and discussion on a plethora of topics. I learned about malaria treatment and alternatives for opportunistic infection prophylaxis while also refreshing myself on topics that will be especially important for my acute care rotation like sedation, analgesia, hypotensive emergencies, and more. Not only did I get challenged and learn about medications, but I also got to have some good discussion with the doctors about differences in healthcare systems in the United States and Uganda. I really appreciate every opportunity I get while I’m here to exchange ideas in this way.

The next day, An came to Nakasero with me and we luckily got to round with one of the same physicians in the ICU. We also reviewed a patient chart with the geriatric specialist, who was able to provide some different input than what we had learned with the cardiology specialist previously on the same case.

The past two days, Joe and I have been at the Infectious Disease Institute (IDI) while An has been at Nakasero. Yesterday we spent some time in the pharmacy observing the workflow. We were impressed by the computer system and general efficiency of the process. We also spent some time shadowing physicians in their patient visits. This led to some very intense discussion on reproductive rights. At the same time, Prosperity and An ended up having quite the debate on gay rights. As we discussed in our afternoon debrief, these can be some very difficult conversations to have and open dialogue is extremely important for progress to be made.

Another issue that has recently become much more important in the world of infectious diseases in Uganda is the current Ebola outbreak. Yesterday a 5-year-old boy died of Ebola and today, that boy’s grandmother succumbed to the disease. Ugandan health authorities are extremely concerned as these are the first cases of the virus reaching across the border from the Democratic Republic of Congo, where over a thousand people have died in this recent Ebola outbreak. When we arrived at IDI, we were asked to read and reflect on an article about the Ebola epidemic from 2013-2016 that discussed strategies for identification of patients presenting potential symptoms. The team is now reassessing these tactics and making sure they are as prepared as possible in case the outbreak reaches Kampala.

In the afternoon, we met with a physician working on preventing antimicrobial resistance throughout the country by improving access to laboratory testing, surveillance, and education. We have all seen some pretty shocking cases of patients with infections caused by extremely resistant pathogens, so we were very interested to learn how this issue is being addressed in Uganda. I really enjoyed the conversation we had with this doctor and gaining his perspective on how provider behavior can be changed for the benefit of antimicrobial stewardship.

We continued our full day with a visit to a community pharmacy in Kampala. We sat down in a meeting room with three pharmacists and had all our questions about pharmacy practice in Uganda answered. We learned that pharmacy technicians in Uganda require 3 years of education and often are very close in healthcare and pharmacy knowledge as the pharmacists who have 4 years of formal education followed by an internship year. After our discussion time, we got a tour of the pharmacy and were extremely impressed by the medication supply available (and the cheap prices!). While this pharmacy is very modern and advanced in the services it provides relative to other community pharmacies in the country, we really appreciated gaining a better understanding of the role of the pharmacist in Ugandan healthcare and seeing what a pharmacy could be like. I’m looking forward to seeing what our final week in Uganda will bring!

Richard (pharmacist), Joe, Melanie, An, and Olivia at First Pharmacy in Kampala

Differences in practice of pharmacy in Uganda vs U.S.

A post by An Le, PD4

It’s frightening to think how three weeks has gone by so fast already!!

Although I grew up in Vietnam, where is known for its notorious traffic, I have to say that Ugandan traffic IS even more terrifying. This past week, we had to say goodbye to Dr. Nicol, as she returned to the United States. For the rest of our time in Uganda, Prosperity Eneh, who just recently completed the Global Pharmacy Engagement, Education, and Research fellowship at the University of Minnesota, will be with us for rest of our time. As Prosperity has been to Uganda before, we are very excited to learn more about Ugandan health system and explore the Kampala city with her. Between my previous post and this post, Joe, Melanie, and I had so many more incredible experiences that allowed us to further submerge in the Ugandan culture and healthcare system.

Before Dr. Nicol went back to the US., the four of us got to spend a 3-day weekend at the Murchison Falls National Park, where we were all amazed by the beauty of the Ugandan wildlife. Spending the whole day driving through the safari to be close to the wild animals was completely worthwhile. This might sound dramatic, but I don’t think words can’t describe my excitement when we were 10-20 feet away from a group of giraffes and elephants. I’m not sure if I should say it here, but Joe and I were looking forward to seeing some chasing between the animals. The 3-day weekend zipped through! When we got back to Kampala city, we found out we got another day off because of Eid al-Fitr celebration, marking the end of Ramadan. In order to decide which day marks the end of Ramadan, the Muslim advisers had to watch the moon. Therefore, a lot of institutions, meetings, and other pre-scheduled activities had to adapt to the celebration.

I also just finished my rotation at Kirrudu General hospital. As I briefly mentioned in my previous blog post, Kirrudu General Hospital has one specific ward that houses patients living with HIV, who also concurrently have cryptococcal meningitis. From my understanding, there are three on-going studies being conducted on this floor: AMBITION, ASTRO, and RIFT. I spent the majority of my time with the meningitis team to assess patients for the AMBITON-CM or ASTRO study. AMBITION-CM study is conducted to evaluate the efficacy and safety profile of a single high-dose liposomal amphotericin compared to the conventional 7-day deoxycholate amphotericin. Being with the clinical team the past week has allowed me to have a closer exposure to the entirety of clinical research process from screening patients for eligibility, obtaining patients’ consent, to randomizing patients into different treatment arms in the study. It was extremely interesting to see the whole process occurs in real life. In contrast to the United States, all patients have to share one common large room on the ward. Their family members take turn to be with the patients, so they can help the nurses remove the catheter or set up the feeding tube. During my time with the rounding team, I was blown away by how motivated the patients are to improve their health in spite of the limited resources.

Ironically, the topic for my journal club was on a phase 2 study assessing the efficacy and safety of 3 alternative schedules of intermittent high-dose liposomal amphotericin B (single-dose, 2-dose, 3-dose regimen) compared to the conventional dose of 3mg/kg/day liposomal amphotericin B for 14 days. The outcomes of this phase 2 study demonstrated a non-inferiority between a single-dose and conventional therapy of liposomal amphotericin B. This journal club was really helpful for me, as my goal is to get better at analyzing the study design and outcomes to review the validity of the study. We also had a very good discussion on different ethical issues within the study, which helped me a chance to look at the study from the different perspective.

This past week, Joe, Melanie, and I also had an opportunity to learn more about the “Pharmacy antiretroviral therapy refill” program. This initiative is implemented at 6 different private pharmacies by the Infectious Disease Institute and Kampala Capital City Authority. Kampala Capital City Authority organizes numbers of outreach programs that collaborate with other institutions on national, regional, district, and community level. This program started in November 2016 with the goal to improve retention and adherence to treatment, direct more care towards critically-ill patients living with HIV, and provide a more flexible medications refill for virologically suppressed patients. In order to be qualified for the program, patients have to show good adherence, be on standard 1st line antiretroviral therapies for at least 1 year, and have no active opportunistic infections. Another Ugandan third year pharmacy student and I travelled to one of the community pharmacy, where this program has been implemented, to interact with patients and the staff to gather feedbacks. These feedbacks will be used to improve the program in the future. From our conversations, the majority of patients really enjoy being in this program, as they think it is more convenient and flexible for them to pick up the medications. The whole visit was done by the nurse, where she discussed with the patients about the medications (adverse events and how to use), answered any questions that the patients had, and provided patients the medications. During the conversation with the pharmacist at IDI, Joe, Melanie, and I were surprised when we learned that the pharmacist’s roles within this program is to serve as supervisor to make sure the pharmacy meets the criteria to stay in the program, as the counseling and recommendations are usually done by the nursing staff and pharmacy technicians. This is completely opposite from what we normally see in the United States! The pharmacist also explained to us that it is more cost-effective to conduct training the nurses and pharmacy technician on how to counsel, monitor side effects, and make any recommendations to the patients. Moving forwards, the program is hoping to broaden the program to PReP and PEP, integrate more technologies for data management, and scale up beyond 6 pharmacies.

On Saturday, Joe, Melanie, and I challenged ourselves and went to Jinja for rafting the whole day on the Niles river. We magically survived all the madness that the rapids brought to us. We also got to meet two other PA students from South Caroline and learned about their clinical experience in Uganda.
                                      
Even though the past 3 weeks went by too fast, we are so thankful for all the learning opportunities, as they let us step out of our comfort zone to acquire numbers of interesting clinical and cultural knowledge. This rotation has truly been eye-opening for all of us! With only less than 2 weeks left in Uganda, we are hoping to learn more about the roles of pharmacists in Uganda in various settings, so we can compare and contrast with the roles of pharmacists in the U.S.

Cultural competence in a potpourri of clinical settings

A post by Joe Corbino, PD4

If there is one lesson I have learned during my three weeks in Uganda so far is that there is such a thing as “Uganda Time”. You can do your best to have your day planned out, but this country always seems to throw a curveball at you somehow! Nevertheless, even with adjustments made to our daily schedules we are all having the best time. This past week has been full of varying clinical experiences, a journal club covering cryptococcal meningitis therapy, patient case presentations, and time exploring more of the capitol city of Kampala.

This week we were joined by Prosperity Eneh, a recent University of Minnesota pharmacy fellow and member of the Nicol lab, who will be spending the remaining two weeks with us. We were also informed at the beginning of the week that Eid would be occurring, marking the end of Ramadan, at some point during the week. This was entirely dependent on when the moon was sighted in Saudi Arabia, which made it a bit challenging to make plans for the rest of the week. Luckily for us, the holiday fell on Tuesday meaning that we all got to enjoy a four-day weekend due to an additional public holiday on Monday! After three great weeks we had to bid farewell to Dr. Nicol as she returned to the United States. 

Shubh Community Pharmacy

On Thursday, An, Melanie, and myself were paired with three Ugandan pharmacy students that had also just finished their third year to travel to three separate pharmacies located in communities across different districts of Kampala. These pharmacies are part of a unique program supported by the Infectious Disease Institute (IDI) and Kampala Capitol City Association (KCCA). It is meant to provide easier access to medications to individuals that are currently receiving first line antiretroviral therapy, are currently controlled on this regimen, and have adherence greater than 95%. During visits to their respective community pharmacies, patients meet with a nurse to go over any issues that they are currently having with their medications, have questions answered, and receive a two months supply. With our respective pharmacy student, we were able to speak with the patients to get a better understanding of their experience in the program and areas that there could be improvement. The overwhelming majority of individuals shared that they enjoyed the personal relationships they had developed with the nurses and the reduced wait time to receive their medications.

It was extremely interesting to get a better understanding of how community practice works in a foreign country. While a pharmacist will own their respective pharmacy, often the only individuals that you will find working there are technicians and possibly nurses. These individuals are able to dispense medications, counsel, and make recommendations to patients. This has been a difficult concept for me to grasp as there is a clear delineation in the United States in what a pharmacy technician can and cannot do. When I brought up this difference with the Ugandan pharmacists at IDI, they shared that it really came down to the ability of pharmacists in the country and what their defined role is for the population. While integration of pharmacists into the above-mentioned program would be a great progress for the profession, I keep reminding myself that it is important to think about the logistics that need to be taken into consideration. The cost of a pharmacist is substantially higher than that of the nurse as well as the training that is required in order for them to fulfill this role.

After a schedule change due to rain storm and other unforeseen circumstances, I spent the morning at Nakasero Hospital with Melanie and Prosperity. This is a private hospital where patients come and pay for the services that they receive. This was much different from my exposure at Mulago and Kiruddu as Nakasero resembles hospitals that I normally see in the United States. Melanie and I were able to attend rounds with a Medical Officer, who is much like a physician’s assistant back home, and see a wide variety of patients. We also had an excellent discussion  on a complex patient case that had been referred in. I am really excited about spending more time in this setting during the last week in Uganda as I believe it will give me a wide exposure to several different disease states. 

Nakasero Hospital

Nakasero Hospital

As we were getting ready to leave Nakasero, we were informed that there was a case for an autopsy study that Dr. Nicol is currently conducting. Melanie and I jumped at the opportunity as this was something we had never been able to experience before. Walking into the morgue was a humbling experience making me reflect how fragile and special human life is. The individuals performing the autopsy took the time to explain to us all of the samples that would be taken during the procedure for the research study as well as the process for the actual autopsy. It was interesting to hear about how the consent process is carried out with families and what the beliefs are surrounding death and autopsies in general in the Ugandan culture. This was another great opportunity to reflect on how important it is to always remain culturally competent when providing care as individuals approach situations from a multitude of different angles.

It is hard to believe that my time in Uganda is already half way over. I have learned so much during my time here and I feel that it will have a lasting impact on my life moving forward. I am excited for the remaining two weeks and for all that they hold in store! An, Melanie, and me are heading to Jinja this weekend to the source of the Nile river to go on a white-water rafting excursion. Stay tuned for pictures and updated on how that adventure went in a few days!!

That's a Lot of Ambisome!

A post by Melanie Nicol

Greetings readers! We are still on a bit of a high regarding our safari trip. This is my third time on a safari and my second time in Murchison but that did not make the trip any less awe-inspiring. I am so blessed to have the opportunity to experience something that many will never get to do.

Although we planned for the long weekend since I knew June 3rd, Martyrs' Day was a public holiday in Uganda, it was only last week we learned that Eid al-Fitr, the end of Ramadan, would also fall this week.  We found out late last evening that Eid was today (June 4th) meaning we actually have a 4-day weekend. Apparently the day that Eid will fall on is not known ahead of time so we could not have planned for this anyway. Since most of the sites and partners that we would be working with today have a holiday, we made today a "project day". We have been working in a local coffee shop, Endiro Cafe, which is a local little Mzungu Haven within walking distance of the Minnesota House. We got here a little after 10. Around 1pm it started pouring rain- 2 hours later it hasn't let up. We may be stuck here for quite awhile. There is food, coffee, internet, and electricity so we are all happy campers though :)

As you've read in the students posts- they have been rotating through a couple of different locations and experiences during their time here. One of those rotations is with the meningitis team at Kiruddu Hospital. I have previously described some about the cryptococcal meningitis research team in a previous post (see Mushroom Meningitis of Uganda). Observing this team is a great example for the students to see integration of clinical care and clinical research.  Although to some extent this is true in the U.S. (i.e. for many difficult to treat pediatric cancers standard of care is to enroll in a clinical trial so they have access to the newest treatment advances). I think in some ways this integration is especially true in resource limited settings.

Since last year, there have been many updates on the meningitis research projects. It is an exciting time for the meningitis team. Many new drugs and formulations will be tested over the coming months-years. Currently, Kampala is a site for the AMBITION-CM (link) which is investigating a single high-dose liposomal amphotericin compared to the standard 7 days of de-oxycholate amphotericin.

Member of study team prepares the Ambisome

That's a lot of Ambisome

The next trial to be underway here is the ENACT study which is going to investigate an oral formulation of amphotericin. If successful, this would be a great boost to clinical care as currently amphotericin can only be given IV- infusion related reactions are common. Lastly a clinical trial investigating a new oral "first-in-class" antifungal. New classess of antifungal medications are sorely needed so this study also has the potential to have great impact on the drug development pipeline.

As for my own research with the meningitis team, the autopsy study is still underway. Our first manuscript describing antiretroviral penetration in brain tissue was recently accepted in Clinical Translational Science (will add link when available). We confirmed that CSF is not a good surrogate for brain exposure AND we confirmed that drug penetration (into CSF) is higher in individuals with meningitis, something that has long been suspected but never shown with these drugs in humans. We have now developed a pretty extensive tissue bank and investigations related pharmacokinetics and pharmacodynamics in brain tissue are underway. We are hoping we can identify regimens (both anti-HIV and antifungal) that will be able to erradicate viral and fungal reservoirs in all regions of the central nervous system.

I can't believe it but tomorrow is my last day in Kampala! I have been very impressed with how the students have quickly learned their way around and feel comfortable leaving them in the hands of Prosperity and my collaborators

On Uganda Time : A Safari Adventure

A post by Melanie Mahoney, PD4

It’s hard to believe I’ve been in Uganda for 2 weeks! This past week and weekend has been full of learning and adventure. Last week I spent some more time in the neurosurgery ward and identified a patient case that I will be using to develop a case presentation. This will allow me to focus on one patient and analyze the care received, the patient’s conditions, and possible other treatment options. I’ll be sharing my findings in a presentation with Dr. Nicol, Joe, and An so that we can discuss and learn more from this together.

On Friday I got to go to Kirruddu Hospital for the first time. This hospital is the site for several research studies, including AMBITION, a trial assessing the efficacy of a single dose liposomal amphotericin for patients newly initiated on antiretroviral therapy (ART) for HIV who also have cryptococcal meningitis (CM). Although CM is relatively rare in the United States, it is one of the leading causes of death in HIV patients in resource limited settings such as Uganda. An and I travelled to Kirruddu in a van with a physician and a nurse involved in the AMBITION study. Before starting rounds, he was told that there was a new patient who might be eligible for the study. The patient had been newly diagnosed with HIV, had just started on ART, and was complaining of headaches, fever, and neck pain (symptoms of meningitis). To diagnose CM, a lumbar puncture is performed. This involves inserting a large needle into the spine to collect a sample of cerebrospinal fluid (CSF). An and I got to assist in this procedure! Once the CSF is collected, a dipstick that detects cryptococcal antigen (CrAg) is placed into the sample. If two lines appear, the test is read as positive. Fortunately for the trial but unfortunately for the patient, the CrAg test was positive, leading to a CM diagnosis. The nurse then described the research study to the patient and went through all the necessary paperwork for enrollment. An and I observed as Dr. Enock randomized the patient into the trial. As students in a health science program we have obviously read papers and interpreted results from many clinical trials so it was very interesting for us to see the process taking place in real life.

This weekend was a different type of exciting! Since Monday was Uganda Martyr’s Day (a national holiday here), we had a three day weekend. We took advantage of this extra day off and went on a safari! We woke up early Saturday morning and hopped in the van for Murchison Falls National Park. Shortly after entering the park we were greeted by dozens of baboons! We thought they were adorable and slowed to take lots of photos. Our opinion of these apes quickly changed. To get to our lodge, we had to take a ferry across the Nile. While waiting for the ferry, we thought it would be good to take out a game (Kingdomino) to play at the picnic table. As we were getting set up we noticed one of the baboons watching us and slowly inching closer. I thought he looked cute and started taking a video. He got closer and closer and then quickly lunged between An and Joe and grabbed the plastic bag that had the game pieces and put it in his mouth. We all screamed and jumped away from the table. Miraculously the baboon quickly realized that the contents of the plastic bag did not include any food and spat it all out. The game was saved but it was still a scary moment for all! Maybe he just wanted to play Kingdomino with us but after that we all kept a close eye on the baboons.

That afternoon we went “looking for cats” in the Jeep. We saw all the animals I had been hoping to see: giraffes, elephants, lions, and more. We even got to see a family of four lion cubs wrestling in the distance which really made my day! We enjoyed a picturesque sunset as we headed back to the lodge for dinner and sleep. The next morning, we did another game drive where we got up close and personal with two lions. It was unreal to see these majestic beasts walking next to the road only about 20 feet away from us. We enjoyed a quick dip in the pool with views of the Nile before leaving for our river cruise. On the boat safari we had views of lots of hippos and even caught sight of a few crocodiles. Seeing these beasts in the river made me a tad bit nervous for our white-water rafting trip we have planned for next weekend!

After a jam-packed couple days, we are now heading back to Kampala for another week of learning. This will be a shorter week since we have today (Monday) off for Uganda Martyr’s Day and will likely have either Tuesday or Wednesday off for Eid. We learned that if the moon is sighted tonight then Eid will be Tuesday and if not it will be on Wednesday. It seems to me like the undetermined nature of this holiday would make it a bit difficult to schedule meetings and other work activities, but hey, we’re on Ugandan time here!

Limited resources, numerous experiences

A post by An Le, PD4

IDI Clinic Building on Mulago campus

After being in Uganda for a little over a week, my two classmates and I are still having a hard time believing that we get to have this learning opportunity in Kampala, Uganda. For the past few days living in a different country, every single experience has been truly rewarding, whether it’s a trip to Gaddafi National Mosque or a rotation at the Infectious Disease Institute (IDI).

The three of us rotate through several different sites including IDI, Kirrudu General Hospital, and the neurosurgery ward within Mulago Hospital. My first rotation is at the IDI, which is located on the campus of Makerere University College of Health Sciences. This institution provides care to approximately 8,000 patients living with HIV and other comorbidities. After one of the pharmacists, Eva, gave us an overview of IDI, I was amazed by how much research has been devoted to different areas to ensure patients in this particular population receive the most optimal care. In spite of the limited resources, the pharmacists and pharmacy students are extremely eager to learn about the U.S. healthcare system and explore various research areas to improve patient care. In Uganda, HIV patients receive isoniazid (a medication for tuberculosis prophylaxis) when they come to the pharmacy to pick up their HIV medications. Tuberculosis is the most common opportunistic infection in HIV patients. However, not all patients have tests done to monitor their liver functions before taking this medication. This was surprising to me because in the United States, we learned that liver function is tested prior to isoniazid treatment since this drug can lead to hepatotoxicity. In order to ensure the medication is safe, Eva and her team are planning on a project, where they are figuring out the most effective method to monitor medication safety and promote the importance of medication adherence. After sharing with the team about how this follow-up process is usually done in the United States, I’m excited to see the outcomes of their project in the next few weeks. 

IDI Education Building, where ATIC is housed

During my rotation at the IDI, Joe, Melanie and I got to visit the AIDS Treatment Information Center (ATIC), which serves as a call center for all health providers and patients in Uganda. Here, we were able to help the provider come up with the plan on how to approach a case study for a patient living with HIV and various other comorbidities. This experience allowed us to learn more how healthcare providers communicate with each other and with the patients in Uganda. One interesting piece of information that we learned while discussing the case with the provider is that there have been a few cases on hyperglycemia as a side effect associated with the use of dolutegravir.

I have now started my next rotation at Kirrudu General Hospital, where I get to round with the cryptococcal meningitis team and monitor each patient in the ward. Rounding with the cryptococcal meningitis team has been a unique experience for me, as I have gotten to see the integration of clinical research and patient care. The majority of the patients in the meningitis research trials are taking anti-retroviral therapy and some of them are also taking medications for tuberculosis prophylaxis. While reviewing these patient’s charts, I was shocked by the low CD4+ counts in these patients, which indicates that they are extremely immunosuppressed. Dr. Nicol, Joe, and I had a good discussion on different topics including drug-drug interactions between dolutegravir and rifampin and between fluconazole and rifampin. These discussions are very helpful for me, as they give me an opportunity to recall what I learned during my didactic courses and see how well I can apply it. While at Kirrudu General Hospital, one thing I noticed was how welcoming the provider was. He was very excited when our group asked if we could join and round with him. He also frequently turned to us and checked to see if we have any input for each patient and was very patient in answering our questions. Joe and I also got to see a lumbar puncture procedure done on one of the patients. A lumbar puncture is performed to collect a cerebrospinal fluid sample for a CrAg test for cryptococcal meningitis diagnosis. This procedure is also conducted on patients with cryptococcal meningitis when their intracranial pressure is too elevated. Looking back on this experience, one thing that surprises me the most is how most the time, the medications might not be adjusted to patient’s kidney/liver function. Most patients usually get the same dose regardless of the kidney/liver function. Although the healthcare providers are aware of the importance of the kidney/liver function when dosing, they don’t have a lot of resources to achieve this goal. Moreover, it’s usually cheaper for the Ugandan hospitals to purchase medications in bulk, which can be challenging for healthcare providers to adjust doses for each patient.

Besides these incredible learning opportunities, Joe, Melanie, and I also spent some time visiting different places around Kampala. At the Gaddafi National Mosque, we got to learn about the history of the mosque and the Muslim religion within Uganda. We also got to see a whole view of the city from on one of the mosque’s towers. Last night we attended a culture troupe show and learned about different traditions across Uganda.

 

Ndere Cultural Troupe Show

Climbing the tower at Gaddafi National Mosque

That’s a wrap for now. I seriously can’t wait to share with you all more about what I get to experience in the future blogs. Stay tuned!

Life in Kampala, and a Review of Tuberculosis

A post by Joe Corbino, PD4

View from Kirrudu General Hospital

After a few days I feel like I am finally getting settled into life in Uganda and my first APPE rotation. So far, I have been able to experience healthcare at the Infectious Disease Institute and Kiruddu General Hospital both of which are situated in different areas of Kampala.

The Infectious Disease Institute is situated on the campus of Makerere University College of Health Sciences. This location functions as a specialized center that cares for individuals living with HIV/AIDS who are also suffering from additional co-morbidities. It is estimated that the location is currently following around 8,000 patients. On our second day in the Uganda, the other pharmacy students and I had the opportunity to interact with a pharmacist and three other interns that were completing a four-week rotation at that site. In Uganda, a pharmacist intern designation is applied to individuals that have finished “undergraduate” pharmacy course work and are now completing a year of rotations.

The most interesting experience that I have had thus far has been following the cryptococcal meningitis team to Kiruddu General Hospital to round on their patients that are currently enrolled in research trials. This experience was very different from what I am used to in the United States as patients are grouped into wards, or giant open rooms, rather than individual rooms. One thing that I noticed right away was the amount of family present. I learned that unlike in the United States, families in Uganda will often stay with the patient during the course of their hospital stay administering oral medications, preparing small meals, and sleeping on the floor at night as hospitals are not equipped to provide many of these services. When I arrived a physician was quick to notice that I was a student and offered to allow me to shadow her for most of the morning. This included watching two lumbar punctures in patients that were enrolled in her research study surrounding TB-meningitis. After this I was taken, along with Dr. Nicol, to the microbiology lab to witness how patient samples are handled for further investigational analysis. During my remaining time at the hospital, I was able to join two additional physicians to complete their rounds.

View of Kampala from the top of the minaret at Gaddafi National Mosque 

Inside of Gaddafi National Mosque 

It will never cease to amaze me the severity of immunodeficiency that the patients I have seen are experiencing. One way that this is measured is to look at an immune cell that we refer to as CD4-positive T-lymphocytes. Individuals are considered to be at the greatest risk for opportunistic infections when their CD4 count is less than 200 cells/mL. Almost all of these patients had CD4 levels that were 2-4 cells/mL. This has allowed me to reflect on two things. First, individuals in developed areas of the world are extremely fortunate to generally have access to comprehensive medical care that affords them the latest advances in HIV therapy. Second, improving the lives of individuals suffering from HIV/AIDS in developing countries is something that I want to be invested in for the foreseeable future.

I thought I would take some time to give some brief information on the subject of TB-meningitis for my family, fellow pharmacy friends, and anyone else that may be reading this blog! Tuberculosis (TB) is a disease that is caused by the organism Mycobacterium tuberculosis. The organism is spread through the air and more commonly infects individuals with compromised immune systems, such as those suffering from HIV/AIDS. In school we are taught that the disease generally manifests itself in the lungs, but it is possible that it can disseminate or spread to other areas of the body. Individuals affected commonly present with a fever and headache. They may additionally appear confused if the disease is in a later stage. A confirmatory diagnosis is made through analysis of cerebrospinal fluid, which has high protein, low glucose and a raised number of lymphocytes (immune cells). As is seen in regular TB treatment, individuals are treated with an induction phase consisting of isoniazid, rifampicin, pyrazinamide and ethambutol for two months followed by a consolidation phase of isoniazid and rifampicin for ten more months.

An and Melanie in front of Namirembe Cathedral

Aside from the clinical experiences scheduled this APPE rotation, I have had ample opportunity to explore Kampala and see how beautiful and vibrant of a city it is! So far, I have had the opportunity to go to a craft market, the second largest mosque in Africa, and various delicious restaurants near the Minnesota house. Stay tuned for more updates in the coming week from An, Melanie, and Dr. Nicol!