Monday, September 28, 2015

Mbarara part 2

J. Reisel

The second project that I was able to continue work on while in Mbarara, Uganda was focused on Typhoid Intestinal Perforations or TIP.  This is a project that my Ugandan Co-PI and I developed over a year ago, but have yet to be able to give the attention it needed until I was able to come back to Uganda and work on it full time. 

Typhoid Fever is a life-threatening illness endemic to many low-and middle-income countries (LMICs) due to poor sanitation and water quality. If left untreated, it progresses to perforations of the intestines, commonly referred to as TIP. There are an estimated 12-20 million cases of Salmonella Typhi infections per year, however, due to a dearth of research on this topic, this is largely modeled data that does not account for the incidence of Typhoid perforations; however, in one study from Western Uganda, nearly half of all Typhoid cases progressed to TIP and the majority of patients affected were 19 years or younger. Little progress has been made in the prevention or treatment of this infectious disease.
The best treatment of TIP is prevention. Unfortunately, barriers to preventing and treating Typhoid infections are significant in the limited-resource setting. Without proper antibiotic treatment, a bacterial infection becomes a surgical emergency. However, surgical care is not straightforward in this population. Many patients in LMICs are mal-nourished and immune suppressed.  When compounded with delays to care, such patients are systemically ill and cannot tolerate an extended surgical procedure under anesthesia. Post-operative mortality rates reported for TIP have been as high as 50% and we see many of these complications in Mbarara. Currently there is no evidenced-based standard to approach such cases of TIP, and surgical providers rely on instinct to inform their clinical decisions. Borrowing from the pediatric and emergency surgery literature, my Ugandan collaborators and I thought a “Planned Second Look” (PSL) procedure might improve outcomes, however this has yet to be studied in TIP.
PSL procedures are well supported in the literature across all income levels and age groups in cases of trauma, necrotizing enterocolitis, and aggressive infection. In a PSL, the index operation is an abbreviated laparotomy, infection control, and wash out in an unstable patient so as to minimize exposure to stressful anesthetic agents that may cause hypothermia, hypotension, and acidosis. This is followed by post-operative stabilization of the patient before undergoing the definitive procedure, usually within 24-48 hours.  The PSL also allows providers to detect progression or regression of disease on the PSL, making decisions for definitive management more judicious. In the case of this proposed study for TIP, a PSL would be indicated only in patients deemed unable to withstand a protracted surgical procedure, as determined by the Mannheim Peritonitis Index (MPI).
My month in Mbarara allowed me to really focus on this project – and as a result, our research team was able to present the project to the Department of Surgery at MRRH – and they received it well.  Everyone who has worked in the operating theaters at MRRH has seen the terrible disease progression of TIP and recognizes the need to improve our outcomes in treating these patients.  Following the Department’s approval, we were then able to develop a study protocol and develop our IRB.  It was a busy but incredibly rewarding month in Mbarara!
From Right to Left: Francis Bajunirwe, Johanna Riesel, David Mutiibwa, Martin Situma, and Francis Bajunirwe:  The Typhoid Intestinal Study Team, after finalizing our study protocol at MRRH. 

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