Global Health/International 2019 Projects

Project Title: A Case for Global Surgical Equity: Assessing Pediatric Surgical Outcomes in Kigali, Rwanda

Faculty Mentor’s Name: Dr. Robin Petroze
Phone: 352-273-8825

Student’s Name: James Davis and Kyung Woo Hong

Project Description:

In 2008, Paul Farmer avowed global surgery as the “neglected stepchild of global health”.1 Although there has been significant progress in global medicine in regard to communicable diseases, global surgical diseases lag behind. In 2010, 30-32.9% of the global burden were deemed to be surgical.2,3 This estimates to approximately 16.9 million deaths, which is higher than the combination of deaths from HIV/AIDS, tuberculosis, and malaria (3.83 million).3,4 In 2015, the Lancet Commission estimated that five billion people are without access to safe, affordable surgical and anesthesia care when needed.3

Congenital surgical diseases are prime examples of this disparity. Gastroschisis, a defect where the intestines protrude out of an opening in the abdominal wall at birth, is one of the most common congenital abnormalities at approximately 1 in 2000 births and has been increasing in incidence.6,7 The survival rate differs significantly between high-income countries (HIC) where survival is >95% with limited long-term morbidity and low-income countries (LIC) where survival is less than 25% and often closer to 0%.6 This could be in part due to the high cost of care for gastroschisis and the influence of sepsis and poor access to parenteral nutrition in LIC.9 However, new techniques to close the defect at the bedside without the need for neonatal ventilation as well as improved initial neonatal resuscitation and sepsis management make gastroschisis a logical target for expanded pediatric surgical services.6,10

Rwanda is a small nation in sub-Saharan Africa that had some of the worst health outcomes in the world in the ten years following the genocide. However, Rwanda has made some of the most dramatic strides in health in recent years. Rwanda has universal health insurance, an interhospital ambulance transfer system, several medical schools and postgraduate training programs, and an increasing focus on health equity as a driver for health policy.11 With a population of 12 million people, roughly 50% are under 18 years of age, and 15% are under 5 years of age. Rwanda’s surgeons are scarce, with only 0.15 general surgeons per 100,000 persons and only one pediatric surgeon in the country.8 However, since returning home following his pediatric surgery training, Dr. Edmond Ntaganda has noted increasing survivors from gastroschisis and other congenital disorders. Additionally, he is developing an algorithm for the surgical management of biliary atresia, an acquired obliteration of the extrahepatic biliary tree that is currently a leading cause of liver failure requiring liver transplant around the world. There is practically no information on the epidemiology or outcome of biliary atresia in sub-Saharan Africa, with most patients presenting too late to benefit from surgical intervention.

This research projects focuses specifically on two different pediatric surgical diseases in Rwanda—gastroschisis and biliary atresia. These have been identified by the local pediatric surgeon as targets for quality improvement projects at the main referral and teaching hospital in the country. The goal is to evaluate the local epidemiology, barriers and delays to care, and outcomes in order to continuously improve the quality of care for pediatric patients.

Project Title: Assessing how the microbiome impacts neurological sequelae of Venezuelan Equine Encephalitic Virus (VEEV) in Panama

Faculty Mentor’s Name: Dr. Amy Vittor

Student’s Name: Lauren Aycock

Project Description:

Venezuelan equine encephalitic virus (VEEV) is a mosquito-borne, single-stranded positive sense RNA virus endemic throughout the Americas. Darién, Panama was involved in an encephalitis outbreak in 2010 with 11 confirmed cases of VEEV and 13 confirmed cases of Madariaga virus (MADV, formerly EEEV) [1]. Up to 14% of VEEV patients and 75% of MADV patients have experienced long-lasting neurological sequelae months after clearing the acute encephalitic infection, including paralysis, sensory deficits, recurrent headaches, fatigue, depression, and memory loss [2]. As of yet, researchers do not fully understand the pathogenesis for these sequelae or factors that predispose patients to neurological degeneration after acute encephalitis.

Multiple studies have demonstrated that the microbiome has a significant and complex relationship with neural inflammation and is associated with multiple neurodegenerative diseases, including Parkinson’s Disease, cognitive frailty, Alzheimer’s disease, or other types of dementia. Substantial evidence describes a microbiota-gut-brain axis, where dysregulation, presence or absence of certain bacterial species, or local injury can result in systemic effects. Dysbiosis has been demonstrated to induce systemic pro-inflammatory effects, including altering the blood-brain barrier (BBB) permeability, in addition to directly altering neuroinflammation. These changes in the microbiome are significantly associated with dietary patterns and obesity [3,4].

In the past three decades, Panama has experienced robust economic growth and a cultural shift. Rates of obesity in men during 2010 were six times that of rates in 1982, and females experienced a four-times increase in obesity rates in the same time span. The significant increase in obesity rates among different genders, socioeconomic groups, and ethnic populations signals a shift in overall dietary patterns towards a more Westernized diet [5]. The well-established link between obesity and microbiome dysbiosis suggests that the Panamanian population may experience a higher prevalence of chronic inflammation, which may induce certain neurodegenerative effects of encephalitic viruses endemic to the region. Understanding the link between the microbiome and neurological sequelae in individuals previously infected with VEEV and other encephalitic viruses will help researchers understand the pathogenesis of these viruses, as well as shed light on the intersection between chronic and infectious disease.

Project Title: Outcomes of children with cancer in the Dominican Republic

Faculty Mentor’s Name: Dr. Michael Lauzardo
Phone: 352.273.7682

Student’s Name: Erica Braschi and Paola Trejo

Project Description:

Each year, an estimated 160,000 children around the world are diagnosed with cancer. More than 70 percent of those children do not have access to effective cancer treatment. As a result, as many as 95 percent of children with cancer in developing countries will die. That means that most children with cancer will die needlessly while the cure is in hand for those children fortunate enough to live in countries where modern treatments are available. Over the past 30 years, the treatment of children’s cancer has improved dramatically in rich countries like the United States and many pediatric cancers are now considered curable. But this is not the case for 80 percent of the world’s children who live in poverty stricken countries where cancer is often a death sentence. The Keira Grace Foundation focuses on taking proven cancer treatment to developing nations where the most impact can be made, changing the trajectory of survival rates by more than 400 percent. Modern cancer treatment should be accessible to all children, regardless of where they live. Working in collaboration with the Keira Grace Foundation, this rotation allows students the opportunity to learn first-hand what it takes to transfer world class cures for cancer to a developing country, in this case the Dominican Republic, and will assist in reviewing charts and data to better assess the impacts of these programs on the survival of children with cancer. Medical students can expect to be involved with the data review and collection efforts of this retrospective chart review study. This project is funded partially by The Keira Grace Foundation. FLUENCY IN SPANISH IS REQUIRED.

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