Severe P. falciparum malaria kills people, particularly African children ~ 200,000 per year. Quinine and quinidine infusions were the only antimalarial drugs available to treat severe malaria until recently. The rediscovery of artemisinins in 1972 and subsequent synthesis of artemether and artesunate have provided highly effective alternatives to quinine. Results from meta¬analysis demonstrated that artemether significantly reduced mortality in adult patients with severe malaria from Southeast Asia. Pharmacokinetic studies suggest that the oil¬soluble artemether, which can be given intramuscularly but not intravenously, is poorly and slowly absorbed from the injection site while the water¬soluble artesunate is absorbed rapidly and reliably. The SEAQUAMAT study comparing intravenous artesunate vs quinine among adults and children in 4 Asian countries and demonstrated a significant absolute reduction of mortality of 34.7% (95%CI = 18.5 – 47.6%). A subsequent study (AQUAMAT study) conducted in African children with severe malaria in 9 countries confirmed the excellent efficacy of artesunate with a significant relative reduction of death of 22.5% (95%CI = 8.1 – 36.9%). A large meta¬analysis with more than 7,000 patients also confirmed that artesunate significantly reduced mortality in Africa of 22.5% and that in Asia of 38.6%. Patients treated with quinine had significantly higher incidence of hypoglycemia when compared to those who received artesunate. If these studies had been conducted 20 years earlier, perhaps 4 million patients with severe malaria would not have died particularly African children. Parenteral artesunate should replace quinine everywhere in the world as the first line treatment of severe falciparum malaria. Such a change in policy would save an estimated 200,000 live of children with severe malaria each year. With support from the Global Fund for the fight against AIDS, Tuberculosis and Malaria (GFATM), Laos changed the national policy of severe malaria treatment to artesunate as first line in 2006.

Beriberi (vitamin B1 or thiamin deficiency) is neglected health problem that probably remains as a significant cause of mortality among infants in Asia. There has been very little research in the last 4 decades. Although there are few data from Laos, the clinical experience of Lao pediatricians, along with some data from Mahosot Hospital in Vientiane, suggests that beriberi is probably an important cause of infant mortality, which is currently very high in Laos. Diagnosis of infantile beriberi can be clinically if signs are evident. However, a significant number of infants may have clinical unapparent vitamin B1 deficiency, complicating their illness, which is impossible to diagnose unless biochemical assays are performed. Unapparent vitamin B1 deficiency may complicate the illness of infants presenting with other diseases and supplementary treatment with vitamin B1 could potentially improve their outcome and reduce infant mortality. Two recently published papers by the Wellcome Trust – Mahosot Hospital – Oxford Tropical Medicine Research Collaboration suggested that approximately 13% of Lao sick infants admitted with diarrhea, pneumonia and sepsis (without clinical evidence of beriberi) at the Pediatric Wards, Mahosot Hospital, Vientiane had evidence of biochemical vitamin B1 deficiency particularly among those aged > 2 months. Infants with biochemical vitamin B1 deficiency had higher mortality than those who were not B1 deficient. The study also demonstrated that the activation coefficient (α), which has been used to diagnose vitamin B1 among adults living in non¬rice eating societies, cannot be reliably used for the diagnosis of vitamin B1 deficiency in infants, that basal ETK < 0.59 micromoles/min/gHb is a better biochemical marker of infantile beriberi, and that detection of the cardiac dysfunction marker troponin T may be useful indicator of infantile beriberi. The implication of the findings in these two papers were that (i) since clinical unapparent vitamin B1 deficiency is common among Lao sick infants, co¬treatment with vitamin B1 may reduce disease severity and mortality, (ii) since basal ETK is more accurate than activation coefficient (α) in the diagnosis of infantile beriberi, basal ETK should be used for the diagnosis of vitamin B1 deficiency among infants, and (iii) since troponin T may be useful in the diagnosis of infantile beriberi and as this assay is now available as a bedside test these should be evaluated as accessible markers.

Melioidosis is recognized with increasing frequency in the Lao PDR, and is probably far more common than is currently appreciated. Recommendations for the antibiotic treatment of melioidosis are based on good evidence from a series of large clinical trials conducted mainly in northeast Thailand over the past 25 years. This review summarizes that evidence and considers it in a Lao context. Treatment is usually divided into 2 phases: in the first, or acute phase, parenteral drugs are given for at least 10 days with the aim of preventing death from overwhelming sepsis; in the second, or eradication phase, oral drugs are given, usually to complete a total of 20 weeks, with the aim of preventing relapse. Within these broad generalisations, specific treatment for individual patients needs to be tailored according to clinical manifestations and response, and there remain many unanswered questions. Some patients with very mild infections can probably be cured by oral agents alone. In the Lao PDR, ceftazidime is used for the acute phase, with co-amoxiclav as second line therapy. Co¬trimoxazole plus doxycycline is preferred for the eradication phase, with the alternative of co¬amoxiclav. It is likely that clinical trial evidence will soon support the use of co¬trimoxazole alone. In all cases, the best available supportive care is needed, along with drainage of abscesses whenever possible. Treatment for melioidosis is extremely expensive, but the relative costs have reduced over the past decade. Unfortunately there is no likelihood of any new or cheaper options becoming available in the immediate future.

Rational and Background: University of Health Sciences (UHS) is a unique health institution in Laos that trains medical doctors. Annually more than 150 new medical doctors graduate from this institution but only some of them are recruited in the government health sector and a small number of them continue their higher medical education. Post¬graduate education has increasingly been established and developed at the UHS but very little is known about the expectation and awareness on post¬graduate medical training of the final year medical students. Understanding this issue may help health policy makers to develop strategic plans for medical doctor training appropriately and realistically. Additionally, attitude and suggestion of medical students on the current training program would also be important and essential to improve the curriculum. Methodology: This was a descriptive study to explore the expectation and awareness of the final year medical students on post-graduate medical training at the UHS including their attitude and suggestion towards the current medical training using face¬ to ¬face interview technique with application of pre-designed and pre¬tested questionnaire. Results: Of the 208 final year medical students in the academic year 2010, 186 (89.4%) were interviewed. The proportion of the students with expectation to continue their post¬graduate medical training was 53% (98/186) while the remainder wished to work following their graduation. The percentage of students who wished to continue their training was not significantly different between those who came from provinces [60/120 (50%)] and those who lived in Vientiane Capital [38/66 (58%)], P = 0.32 but this figure was statistically lower among those who had previously worked as health workers compared to those who had not [4/20 (20%) vs 94/166 (57%), P = 0.006]. Only 64.5% of all respondents knew that there is post¬graduate medical training at the UHS. Residency (90%) and family medicine (85%) training programs were the most common post¬graduate medical education of which they were aware but only 21% them correctly understand about residency training program and 16.6% about family medicine program. The training programmes that respondents most commonly stated that they would like to study were OBGY (21%) and Internal Medicine (21%). Among 81 interviewees (43.5%) who expected to work following their graduation, 68 (84%) intended to work for the government sector particularly in the public hospital (75%) for the reason that they wanted to help patients (53%). Only 7.5% of all respondents mentioned that the existing undergraduate training program was good and did not require further improvement while the remainder strongly suggested that the curriculum need to be revised with the emphasis on more practice in the laboratory and hospital. Conclusion: Approximately half of the last-year medical students (academic year 2010) expected to work in clinical practice while the rest wished to continue their further training. But their understanding of the post¬graduate training programs was very low. Most of these students suggested that the existing undergraduate training program be revised with the emphasis on more practice in the laboratory and hospital.

Rational and Background: Diarrhea remains an important cause of morbidity and mortality among children under five (U5) in Laos. Complications of paediatric diarrhea are not uncommonly found among the children admitted to hospitals. Incorrect home¬care practice of children with diarrhea by their guardians may be an important factor contributing to such complications. Methodology: A cross¬sectional, descriptive study was carried out at three central hospitals of Vientiane Capital (Mahosot, Mother and Child, and Setthathirat) between January and February 2010 with objectives to (1) determine the frequency of diarrhea complications among U5 children, (2) describe home care behavior of diarrhea by care¬givers, and (3) correlate such behavior with complications. Results: During the study period 3,722 U5¬children presented or were admitted to the three hospitals. Of these 880 (24%) had diarrhea. Of all children with diarrhea, 262 children and their guardians were studied. All children had been treated before presenting to the study hospitals [home¬care by guardians (52%), treated in public hospitals (34%) and in private clinic (14%)]. One hundred and seventy¬one children (65%) had at least one complication at presentation including dehydration (48.5%), malnutrition (27%) and abdominal distension (12%) with one intussusception (0.4%). Treatments given to the children before presenting to the hospitals were ORS (83%), antibiotics (46%), anti¬diarrheals (25%), herbal medicines (8.5%), and antiemetics (5%). Ninety percent of the guardians had correct knowledge of diarrhea definition and on how to prepare ORS but only 32% and 27% of the guardians increased quantity of daily fluid and food, respectively, to their children during diarrhea. The mean (95%CI) years of schooling of the guardians whose children had complications at presentation were significantly lower than those whose children did not have complications [8.5 (8.1 – 8.9) vs 9.2 (8.2 – 9.6), P = 0.04]. Children who received anti¬diarrheals and antibiotics before presentation were 5 and 3 times, respectively, likely to have complications when compared to those who did not [OR = 4.9, 95%CI = 2.2¬10.9; P < 0.001 and OR = 3.4, 95%CI = 1.9 – 5.9; P < 0.001; respectively]. Children treated with anti-diarrheals and antibiotics prior to presentation were 26 and 5 times, respectively likely to have abdominal distension compared to those without treatment [OR = 26.1, 95%CI = 9.4-72.4; P < 0.001 and OR = 4.8, 95%CI = 2.0¬11.7; P < 0.001; respectively]. Children who were given normal quantity of fluid by the guardians during diarrhea were 1.5 times likely to be dehydrated when compared to those who received increased quantity of fluids [OR = 1.6, 95%CI = 1.1¬2.2; P = 0.002]. Conclusion: Half of Lao U5¬children with diarrhea admitted or presented at central hospitals in Vientiane Capital had been treated by their caregivers and 2/3 of them had at least one complication. These complications were significantly associated with incorrect home¬care practice by the guardians especially treatments with anti¬diarrheals and antibiotics.

Staphylococcus aureus is a common and often serious human pathogen accounting for about a fifth of all cases of bacteraemia with an associated mortality of up to 50%. This review summarizes the aspects of S. aureus bacteraemia that are relevant in a Lao context, including the antibiotic susceptibility patterns seen at Mahosot Hospital, Vientiane over the past 11 years and provides guidance and rationale for clinical management. In the Lao PDR it is the third commonest cause of bacteraemia and the leading cause of skin and soft-tissue infection. Mahosot Hospital has seen almost 200 cases and antibiotic susceptibility testing shows that a significant proportion of isolates are tetracycline and erythromycin resistant. Methicillin-resistance remains very rare, though this is unlikely to continue. Key risk factors for S. aureus disease in financially-poor settings include surgical procedures and previous antibiotic exposure. The identification and removal or drainage of a focus of infection is a key part of the management strategy. Transthoracic echocardiography (TTE) is advised for all patients, where this technique is accessible, and consideration should be given to repeating this test or performing a transoesophageal echocardiogram for patients with a negative TTE, but with a high index of suspicion for infective endocarditis. Treatment with a !-lactam antibiotic (preferably cloxacillin), for 2 weeks in uncomplicated disease and 4 to 6 weeks in complicated disease, is essential to provide cure and prevent relapse. An oral switch may be required, though this should take place only if the patient has been afebrile for 48 hours and has no ongoing complications requiring intervention. Copyright: ∀ 2012 Elliot et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Hand, Foot and Mouth Disease (HFMD) is a common childhood exanthema caused by viruses of the Enterovirus (EV) genus of the Picornaviridae family. The commonest species infecting humans is Human Enterovirus-A (HEV-A) within which group the most frequent serotypes are coxsackievirus A16 (CVA16) and enterovirus 71 (EV71). Other enteroviruses (CV-A2, -A4, -A5, -A6, -A8, -A9, -A10, -A12, -A16, -B3 and –B5) may also be associated with HFMD outbreaks, sporadic cases or asymptomatic infection. HFMD is a highly infectious disease, transmitted through direct contact with respiratory droplets, feces or blister fluid of infective patients or through contact with contaminated environments such as water, food or fomites. The clinical syndromes and severity of cases are diverse, but usually mild and self-limiting. Infants and children under 5 years old are commonly susceptible to the virus. The symptoms of HFMD include fever with blister like lesion or sores in the mouth, on hand, feet and sometimes on the buttocks. In some children with enteroviral disease, neurological complications may occur following a febrile illness but without mucocutaneous manifestations. Severe complications include encephalitis, pneumonia, myocarditis, brainstem encephalitis and acute flaccid paralysis. Epidemics of severe disease have caused great concern in SE and E Asia. High mortality and severe sequelae can be anticipated when the disease is complicated by neurogenic pulmonary edema. Children who have fever for more than three days with a temperature of 38.5°C and a history of lethargy might be at risk of neurological involvement. There are currently neither specific antiviral agents to treat nor vaccines to prevent the infection. Treating severe EV71 brainstem encephalitis patients with intravenous immunoglobulin is recommended by many experts but its efficacy is still doubtful. It is very important to establish a surveillance system to predict future outbreaks and to develop public health measures to control them. If there is an outbreak of HFMD in a school or child care center, classes with 2 or more sick children should be suspended. If there are sick children in many classes, the whole school is recommended to close for 5 to 7 days. During closure, those responsible for the school should ensure that thorough cleaning is carried out before reopening. In addition, parents are advised to ensure that their children adopt a high-standard of personal hygiene and to keep infected children at home until recovery. Copyright: ! 2012 Phommasone K and Dubot-Pérès A. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Rationale and Background: Risk factors associated with Type 2 diabetes mellitus (DM) may differ between population groups and ethnicities. In Lao PDR (Laos), no studies have been conducted to investigate the potential risk factors for Type 2 DM. Methodology: A case-control study was conducted among 150 patients with Type 2 DM who were matched for age and sex with 300 patients presenting at OPD with non-DM diseases, at Setthathirath Hospital between November 30, 2007 and April 30, 2008. Results: Most of the study patients (97.5%) were Lao Loom with an overall mean (95%CI) age of 57.6 (56.6- 58.5) years. The mean (95%CI) daily expense (Lao Kip) was significantly higher in cases [38,700 (35,213- 42,186)] compared to controls [31,400 (29,667-33,132)] (P<0.001). The median (range) number of bottles or cans or glasses of sweet soft drink drunk by the study subjects per week (Pepsi or fruit juice or sugar cane juice) were significantly higher in the cases compared to the controls (P<0.001). Although the proportion of the patients who previously drank alcohol was similar between two groups, the mean (95%CI) number of glasses of whisky drunk by the patients per week was significantly higher in the cases [4.1 (2.8-5.4)] compared to the controls [1.8 (1.4-2.3)] (P<0.001). The percentage of patients with history of cigarette smoking and the mean (95%CI) number of cigarettes smoked per day were not significantly different between the groups (P>0.05). Although the frequency of the patients who did regular physical exercise was not statistically different between the cases (31%) and the controls (27%) (P=0.48), the mean (95%CI) body mass index was significantly higher in the cases [28.3 (27.7-28.9)] compared with the controls [24.9 (24.5-25.4)] (P<0.001). A history of family members with DM was significantly higher among the type 2 DM cases (31%) compared with the controls (16%) (P<0.001), [OR= 2.3; 95%CI = 1.4 - 3.7)]. The history of NSAID/Steroid and traditional-herbal use was associated with type 2 DM [OR = 2.6; 95%CI = 1.3 - 5.0) and OR = 2.7; 95%CI = 1.7 - 4.6), respectively]. Conclusion: Higher expenditure, sweet soft drink consumption, BMI, a history of family members with DM, and history of NSAID/steroid or traditional herb use were risk factors associated with type II DM among Lao patients. Further studies are required in order to confirm the findings of this study especially in different hospitals and parts of Laos. Copyright: ! 2012 Xaysanavong et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Rational and Background: The University of Health Sciences (UHS) is the only health institution training medical doctors in the Lao PDR. The curriculum of the Faculty of Medicine has been developed and improved but no formal evaluation has been performed. Feedbacks on the current learning-teaching situation by medical students are essential and important as they are directly exposed to the real learning-teaching situation. Methodology: This was a descriptive study of feedback from the sixth year medical students (academic year 2010-2011) on the current learning-teaching situation of the Faculty of Medicine, UHS, using a pre-designed, pre-tested and self-administered questionnaire between January – February 2011. Results: Of a total of 162 students, 161 participated in the survey. Only 50% of the respondents reported that they ‘really like’ to study medicine at enrollment. This figure was consistent with the proportion of the students who said that they had successfully passed the entrance examination (56%). However, 86% of the interviewees stated that they ‘like medicine’ after six years of study. Only 44% of the students reported that they had regularly paid attention to the lectures. Approximately half of them mentioned that the basic sciences they had learnt at the beginning of their medical training were useful for medicine and 94% suggested adding anatomy and physiology to the first year class. The majority (78%) of students complained that they had had too little practical experience in the laboratories and hospitals. Forty-two and 54 % suggested that the students should have worked in the hospitals from the second and third years of their training, respectively. More than half (60%) said that the number of lecturers was insufficient, 36% stated that the lecturers are sufficiently knowledgeable, 20% stated that the lecturers were knowledgeable and adequately passed on their knowledge to the students, and 63% of them reported that the lectures were not always updated. Most of the respondents (84%) said that the number of the students in the class was too big and crowded and this negatively affected the learning-teaching atmosphere. Two third of the interviewers said that educational materials and equipment were not adequate, 86% mentioned that textbooks in the University library were not sufficient and lacking while the internet room did not respond to the need of the students (94% said that the internet room opened late in the morning but closed too early, there are not enough computers, and internet speed was too slow). Eighty-three percent of the students complained that the laboratories and hospitals were too small and did not respond to the need of the students. Conclusion: This study clearly demonstrated that the current learning-teaching of the Faculty of Medicine, University of Health Sciences needs to be evaluated, revised, and improved urgently in order to ensure that the newly graduated doctors are fully knowledgeable and qualified. Copyright: ! 2012 Hang et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Rational and Background: Pregnant women are more likely to be at risk of oral disease compared to those who are not pregnant. Oral disease during pregnancy affects not only maternal but also child health. Very little is known about the oral health problems among Lao pregnant women. Methodology: In this descriptive, cross-¬sectional study we described the oral health problems and identified factors related to the oral diseases among Lao women with > 12 weeks of pregnancy who visited the two central hospitals (Mother and Child Health and Mahosot) in Vientiane, Laos between January and February 2010. Oral health was checked by a dentist and an interview was conducted with pregnant women using pre¬designed questionnaires. Data were analyzed using STATA 8.0 and logistic regression was applied to determine factors associated with oral diseases. Results: Five hundred pregnant women aged between 15 and 42 years [Mean (SD) = 26.7 (5.0)] were studied. The proportion of oral disease was 64.6% [dental carries (43%), gingivitis (8.4%), and both carries + gingivitis (13.2%)]. Half of the pregnant women (52.8%) had poor oral health care (brush teeth < 2 times per day). Factors associated with oral disease were monthly income > 2,000,000 LAK/month [OR = 1.8, 95%CI = 1.0 ¬3.0, P = 0.04], teeth brushing < 2 times per day [OR = 2.0, 95%CI = 1.1 ¬3.7, P = 0.03], > 2 pregnancies in their lives [OR = 2.6, 95%CI = 6.0 ¬10.0, P < 0.001], those with > 2 deliveries in their lives [OR = 5.4, 95%CI = 1.2 ¬2.1, P < 0.001], and those with history of oral disease before pregnancy [OR = 2.5, 95%CI = 1.7 ¬3.8, P < 0.001]. Conclusion: This study showed that more than half of Lao pregnant women had oral disease and their oral health self¬-care behavior was low. Poor oral health self-¬care behavior, multiple pregnancies and deliveries, and history of oral disease before pregnancy were factors significantly related with oral disease during pregnancy. Health education on oral health self¬-care and oral health check during ante¬natal clinic visits by the pregnant women should be provided and urgently implemented.