Thursday, April 27, 2017

The Cervical Length Study in Botswana

Ingrid Liff
Maternal Fetal Medicine Fellow at MGH
PGY7

The Cervical Length Study in Botswana: Entry 2

Ingrid and Findo, research assistant for the Botswana Harvard Partnership, outside Scottish Livingstone Hospital in Molepolole, Botswana

I am coming up on my last week of recruitment for the Cervical Length Study in Botswana. This recruitment push so far we have screened 204 women, recruited 23 patients, including 9 HIV-infected women. Our recruiting has been less robust this month due to a scheduling glitch. The usual scheduler at the front desk, a friend of the Cervical Length Study, is actually on maternity leave. We realized this week that the substitute scheduler who does not understand our study as well was sending women away when she felt our schedule was “fully booked”. We fixed the issue this past week, and were able to call the midwives at the surrounding clinics to apologize and tell them to send the patients back who were not seen in ultrasound. I have always promised the midwives that when I am here, no woman who needs a scan in early pregnancy will be sent away. It is one of the ways I support Scottish Livingstone Hospital clinically while I am here.

A large part of fellowship in Maternal Fetal Medicine is teaching and supporting ongoing clinical care in the hospital. When I am at MGH I teach medical students and residents; and when I am at Scottish Livingstone Hospital I teach medical officers and interns. Each morning I arrive at the hospital for morning report before the ultrasound unit opens for scanning. The medical officers and interns report the cases from overnight, and often there are questions and teaching moments that come up. We recently talked about the difficulties of second stage cesarean sections, and the challenges of dating pregnant women presenting in the third trimester without an early ultrasound to confirm gestational age. We talked about arrest of descent, and the diagnosis of cephalo-pelvic disproportion. Last time I was here I gave a lecture on premature rupture of membranes. These are the ways I contribute to clinical teaching while I am here in Botswana recruiting for the study.

I also contribute to clinical care through the ultrasound unit. Midwives from the surrounding clinic and Dr. Rebecca Luckett, the director of OBGYN at Scottish Livingstone Hospital, sometimes send patients for ultrasound. My second month in Botswana I was able to diagnose a rare skeletal dysplasia in a fetus, and counsel the family. About a week ago I scanned a woman with known polyhydramnios. I was able to raise concern for a fetal trachea-esophageal fistula in this patient, along with other related anomalies. Now that I am later in my Maternal-Fetal Medicine training, I am able to contribute more clinically, which is fun.

But the patients of Botswana also continue to teach me, and humble me as a physician. Last week I diagnosed an intrauterine fetal demise at 31 weeks of gestation. As usual, especially since I am still early in my career, I spent most of the scan concerned about how I was going to deliver this terrible news. I looked inferiorly, and thought I identified the cervix continuous with the pregnancy in the setting of an intrauterine pregnancy per routine. There was almost no fluid around the fetus, and the scan was hard for sure. I measured the fetus as well as I could and assessed that the placenta was low and there was clot inferiorly. This patient later failed induction and was taken for a cesarean delivery. Intra-operatively she was diagnosed with an abdominal pregnancy, a rare type of ectopic pregnancy. I felt absolutely terrible that I had missed this very important ultrasound diagnosis. Certainly I will never forget this case as I continue in my career.
 

The Cervical Length Study in Botswana

Ingrid Liff
Maternal Fetal Medicine Fellow at MGH
PGY7

The Cervical Length Study in Botswana: Entry 1

It is a quiet Easter weekend here in Botswana. (The country goes on holiday for the Friday before and the Monday after Easter.) I am using this time to finalize another grant application, and watch some statistics classes through the Harvard Catalyst.

This is a research block for me. I am in Botswana to complete recruitment for the Cervical Length Study, which I started at the beginning of my fellowship to understand whether preterm birth in HIV-infected women is mediated by the cervix. I am working with a great mentor in my department, and great Infectious Disease mentors at the Botswana Harvard Partnership. Each day I drive an hour out to Scottish Livingstone Hospital (SLH), a large district hospital in Molepolole, Botswana where I recruit patients. I spend the days performing ultrasounds in the X-Ray Department. My friend Mr. Mingochi, an ultrasonographer at SLH, is a big supporter of the Cervical Length Study. He always gives me a key to the office and a key to the small room where I perform scans for the hospital and for my study. These keys are a symbol of friendship and of the success of the study so far.
Ingrid and Mr. Mingochi in the ultrasound unit at Scottish Livingstone Hospital in Molepolole, Botswana
I do obstetric scans while I am here, taking part of the work-load off of Mr. Mingochi. I spent most of my first month in Botswana trying to understand how SLH schedules women for ultrasounds during pregnancy. An ultrasound during pregnancy is recommended by the Ministry of Health in Botswana, but often not performed due to limited human resources for ultrasound. (The first months I was in Molepolole recruiting for the study, Mr. Mingochi was the only sonographer in the hospital – responsible for inpatient and outpatient scans for brain, abdomen, breast, thyroid, and other pathology, not to mention routine obstetric scans.) After months of outreach and working with the scheduler at the front desk of the X-Ray Department, some women present for a scan prior to 32 weeks gestation during my recruiting pushes.

For the Cervical Length Study, I recruit volunteers between 22 weeks and 24 weeks and 6 days of gestation. If a woman chooses to be in the study, she signs a consent, fills out a brief questionnaire, and we measure her cervix by transvaginal ultrasound. A research assistant, the lovely Findo, helps me explain the study, consent patients, and complete the questionnaires.

This is my last recruiting push for the Cervical Length Study. So far, things are going well. We have recruited almost 20 patients. We also did outreach to the surrounding clinics this past week to say thank you to the midwives who send patients for ultrasound while I am here. We always bring small gifts of Harvard pens or chocolates, another key to the success of the study thus far.

“The Length of the Cervix Among HIV-infected Women at Scottish Livingstone Hospital in Botswana” is also supported by the Queenan Fellowships for Global Health – Investigator-Initiated Research, The Pregnancy Foundation.

Cardiothoracic Surgery in Nigeria

Asishana Avo Osho, MD, MPH
Resident in General and Cardiothoracic Surgery at Massachusetts General Hospitala
PGY 3

Cardiothoracic Surgery in Nigeria

Driving from Lekki to Ilishan-Remo (Ogun state) served as a reminder of the range of living environments that Nigeria offers. Starting in Lekki with its nice “roundabouts” and nicely constructed toll gates, I drove through Victoria Island and Ikoyi where opulent car dealerships and fancily named restaurants – the “Golden Gate” restaurant to give one example – line the streets. These areas constitute “Lagos Island” where much of the Money in Lagos is exchanged. The financial market share of the Island is soon to increase exponentially as the much advertised Eko-Atlantic city – heralded as the new financial center of Nigeria, and maybe even of West Africa – branches out from Victoria Island. The 25 km2 city, created in the Atlantic Ocean by land-fill is very much in its inception, but almost all the available land has been sold for upwards of $2,000 (US) per square meter. The transition from Ikoyi to the Lagos mainland is somewhat gradual, but still noticeable as the number of people lining the streets more than triples while the number of well-maintained buildings decreases.

As we get toward the outer edges of Lagos, the nicer cars including a few Porches, “Bmers” and “G-wagons” are replaced with an infinite number of Danfos – the yellow and black “open air” commuter buses that most “Lagosians” depend on for transport to and from work. The cars begin to take on this brownish hue as the dust from poorly maintained roads rises and settles all over them. Over-crowded shanty towns can be seen miles into the distance interrupted only by “Mega Church Cities”, patronized by swarms of Nigerians in pursuit of “salvation”. We then exit Lagos into Ogun state, via Shagamu, where there are few cars on the road at all. We got lost in a village – Google Maps had been faithful till that point, but let us down a few miles from our destination – but ultimately made it to Babcock university by mid-morning (Three and half hours after we set out – 58 kilometers or 36 miles in total)
Babcock University Gates
 The gates of Babcock university stand tall in Ilishan-Remo a small town in Ogun state. Operated by the Nigerian Seventh Day Adventist Church since 1959, Babcock University has faculties in various fields including medicine and nursing. The campus itself is somewhat of a mini city with separate buildings for primary and secondary school students, a university owned hotel, and a large store, also owned and operated by the university. Overall the feel is not too unlike my Catholic Boarding High School in Abuja, Nigeria, just on a much larger scale. Tristate Cardiovascular – my “home base” – is located just to the left of the Babcock University Emergency Department. With large signs in front of the building and doors that are styled quite differently from the rest of the teaching hospital campus, it is evident that Tristate is an independent entity within the University campus. I would quickly learn however, that Tristate is very well integrated with the rest of the teaching hospital sharing in addition to the location, patients, pharmacies, laboratories and imaging departments. 
Tristate Cardiovascular Entrance
Tristate Cardiovascular was established in 2015 to provide the full spectrum of cardiovascular care – including open surgical and percutaneous techniques – within Nigeria, on a regular basis. The dominant model in Nigeria for complex procedural cardiac care remains medical tourism, whether it be patients traveling for care or foreign specialists coming into the county for short term stints. The goal with tristate appears to be some degree of industry disruption as the whole team is based in Nigeria and provides routine and emergent cardiac care on a regular basis. Having completed over 100 open heart surgeries, it would not be premature to say that Tristate is making some meaningful contributions to changing the standard.    

My first interaction with Tristate staff was a gentle scolding from the security staff as I attempted to step into the center with my “street shoes”. I had seen the nearly full shoe rack just in front of the center, and the row of white sandals just inside the door, but it didn’t register that I wouldn’t be allowed in with my regular shoes. After trading my black Aldos for clean white sandals, I continued into the air-conditioned waiting room. I was then led into the main building which has a simple set up: a central physician call room surrounded by the rest of the core facilities including a large major cardiac operating room, a separate large cardiac catheterization lab with a standard control room set up, a two-bed step down unit and an open 9 bed intensive care unit with one isolation room. Besides the open set up of the Intensive Care Unit, the entire facility including equipment and operating rooms seemed on par with what I’ve seen at multiple major academic centers in the United States – testament to the lofty aspirations of the Tristate leadership. Through the course of my stay at Tristate, I would ultimately be involved as a first assistant in almost 10 major cases including adult and pediatric open heart surgeries. As with the facilities, the operating experience was not very different from what I am used to.
Operating Room Suite

Catheterization Lab Suite
Walking through the center and meeting the staff that first day, I wondered if there was a color code for scrubs – ICU nurses seemed to be in pink, OR nurses in blue, catheterization lab techs in brown and our lone cardiology fellow in green. Regardless of the color, everyone seemed very friendly and excited to be at work. At the time, we had only a few patients in house but I remained very excited about the possibilities. Admittedly I expected much less and was very impressed with what had been set up at Tristate. I went to bed that first night with one thought in my mind: So much to look forward to…