Interpersonal violence in peacetime Malawi.

Background: The contribution of interpersonal violence (IPV) to trauma burden varies greatly by region. The high rates of IPV in sub-Saharan Africa are thought to relate in part to the high rates of collective violence. Malawi, a country with no history of internal collective violence, provides an excellent setting to evaluate whether collective violence drives the high rates of IPV in this region. Methods: This is a retrospective review of a prospective trauma registry from 2009 through 2016 at Kamuzu Central Hospital in Lilongwe, Malawi. Adult (\u3e16 years) victims of IPV were compared with non-intentional trauma victims. Log binomial regression determined factors associated with increased risk of mortality for victims of IPV. Results: Of 72 488 trauma patients, 25 008 (34.5%) suffered IPV. Victims of IPV were more often male (80.2% vs. 74.8%; p Discussion: Even in a sub-Saharan country that never experienced internal collective violence, IPV injury rates are high. Public health efforts to measure and address alcohol use, and studies to determine the role of mob justice, poverty, and intimate partner violence in IPV, in Malawi are needed. Level of evidence: Level III

Some Observations of Short-eared Owl, Asio flammeus, Ecology on Arctic Tundra, Yukon, Canada

We investigated nesting behavior, food habits, and interspecific interactions of Short-eared Owls (Asio flammeus) within an arctic tundra raptor community on Herschel Island and Komakuk Beach, northern Yukon, Canada. Short-eared Owls were the least common nesting raptor. We found only three nests, all on Herschel Island. All nests were on relatively elevated sites with fairly substantial vegetative cover. All nests failed in the egg stage, from a combination of human disturbance and possible predation by Arctic Fox (Vulpes lagopus) or Red Fox (Vulpes vulpes). Short-eared Owls nested only in years when small rodent densities were at least 4 to 5 individuals per hectare in the spring. Short-eared Owls ate Northern Collared Lemmings (Dicrostonyx groenlandicus), Brown Lemmings (Lemmus trimucronatus), and Tundra Voles (Microtus oeconomus) almost exclusively, without clear selectivity. Peregrine Falcons (Falco peregrinus) killed two adult Short-eared Owls. In northern Yukon, the Short-eared Owl remains an uncommon summer resident and uses the region as a migration route. Spring rodent densities and interspecific predation are prominent limiting factors, and human disturbance also limits nesting success. We recommend restricting access to most tundra areas during periods when the birds are mating, initiating nesting, and incubating eggs. We recommend that human infrastructure be designed so that it cannot support novel nesting (and therefore local range expansion) by other nesting raptors that compete with and prey on Short-earned Owls

Evaluation of a Technique to Trap Lemmings Under the Snow

We attempted to live trap lemmings under the snow in their preferred winter habitat at two sites in the Canadian Arctic using chimney-like boxes. Lemmings used the boxes during winter, but we had very low trapping success in April and May. During spring trapping, in contrast to most of the winter, subnivean temperatures became colder than ambient air temperatures. We hypothesize that our low success in spring resulted from lemmings’ leaving the deeper snow areas where our boxes were located and moving to shallower snow or exposed tundra. We suggest that the trapping boxes could be successful if trapping occurred earlier during winter.Nous avons tenté de capturer des lemmings sous la neige dans leur habitat hivernal préféré en utilisant des boîtes en forme de cheminée à deux sites situés dans l’Arctique canadien. Les boîtes ont été utilisées par les lemmings durant l’hiver mais nous avons eu un très faible succès de capture en avril et mai. Contrairement à la majorité de l’hiver, les températures sous-nivales étaient plus froides que les températures de l’air pendant que nous avons trappé au printemps. Nous émettons l’hypothèse que notre faible succès au printemps est dû au déplacement des lemmings des sites de fort enneigement, où nos boîtes étaient installées, vers ceux de faible enneigement ou vers la toundra exposée. Nous suggérons que les boîtes de trappage pourraient être plus utiles si le trappage se faisait plus tôt au courant de l’hiver

Comparative outcomes between COVID-19 and influenza patients placed on veno-venous extracorporeal membrane oxygenation for severe ARDS

Background ECMO is an established supportive adjunct for patients with severe, refractory ARDS from viral pneumonia. However, the exact role and timing of ECMO for COVID-19 patients remains unclear. Methods We conducted a retrospective comparison of the first 32 patients with COVID-19-associated ARDS to the last 28 patients with influenza-associated ARDS placed on V-V ECMO. We compared patient factors between the two cohorts and used survival analysis to compare the hazard of mortality over sixty days post-cannulation.Results COVID-19 patients were older (mean 47.8 vs. 41.2 years, p = 0.033), had more ventilator days before cannulation (mean 4.5 vs. 1.5 days, p < 0.001). Crude in-hospital mortality was significantly higher in the COVID-19 cohort at 65.6% (n = 21/32) versus 36.3% (n = 11/28, p = 0.041). The adjusted hazard ratio over sixty days for COVID-19 patients was 2.81 (95% CI 1.07, 7.35) after adjusting for age, race, ECMO-associated organ failure, and Charlson Comorbidity Index. Conclusion ECMO has a role in severe ARDS associated with COVID-19 but providers should carefully weigh patient factors when utilizing this scarce resource in favor of influenza pneumonia

Cost effectiveness analysis of clinically driven versus routine laboratory monitoring of antiretroviral therapy in Uganda and Zimbabwe.

BACKGROUND: Despite funding constraints for treatment programmes in Africa, the costs and economic consequences of routine laboratory monitoring for efficacy and toxicity of antiretroviral therapy (ART) have rarely been evaluated. METHODS: Cost-effectiveness analysis was conducted in the DART trial (ISRCTN13968779). Adults in Uganda/Zimbabwe starting ART were randomised to clinically-driven monitoring (CDM) or laboratory and clinical monitoring (LCM); individual patient data on healthcare resource utilisation and outcomes were valued with primary economic costs and utilities. Total costs of first/second-line ART, routine 12-weekly CD4 and biochemistry/haematology tests, additional diagnostic investigations, clinic visits, concomitant medications and hospitalisations were considered from the public healthcare sector perspective. A Markov model was used to extrapolate costs and benefits 20 years beyond the trial. RESULTS: 3316 (1660LCM;1656CDM) symptomatic, immunosuppressed ART-naive adults (median (IQR) age 37 (32,42); CD4 86 (31,139) cells/mm(3)) were followed for median 4.9 years. LCM had a mean 0.112 year (41 days) survival benefit at an additional mean cost of $765 [95$7386 [3277,dominated] per life-year gained and $7793 [4442,39179] per quality-adjusted life year gained. Routine toxicity tests were prominent cost-drivers and had no benefit. With 12-weekly CD4 monitoring from year 2 on ART, low-cost second-line ART, but without toxicity monitoring, CD4 test costs need to fall below$3.78 to become cost-effective (<3xper-capita GDP, following WHO benchmarks). CD4 monitoring at current costs as undertaken in DART was not cost-effective in the long-term. CONCLUSIONS: There is no rationale for routine toxicity monitoring, which did not affect outcomes and was costly. Even though beneficial, there is little justification for routine 12-weekly CD4 monitoring of ART at current test costs in low-income African countries. CD4 monitoring, restricted to the second year on ART onwards, could be cost-effective with lower cost second-line therapy and development of a cheaper, ideally point-of-care, CD4 test

Discovery of a Brown Dwarf Companion to Gliese 570ABC: A 2MASS T Dwarf Significantly Cooler than Gliese 229B

We report the discovery of a widely separated (258\farcs3\pm0\farcs4) T dwarf companion to the Gl 570ABC system. This new component, Gl 570D, was initially identified from the Two Micron All Sky Survey (2MASS). Its near-infrared spectrum shows the 1.6 and 2.2 \micron CH$_4$ absorption bands characteristic of T dwarfs, while its common proper motion with the Gl 570ABC system confirms companionship. Gl 570D (M$_J$ = 16.47$\pm$0.07) is nearly a full magnitude dimmer than the only other known T dwarf companion, Gl 229B, and estimates of L = (2.8$\pm$0.3)x10$^{-6}$ L_{\sun} and T$_{eff}$ = 750$\pm$50 K make it significantly cooler and less luminous than any other known brown dwarf companion. Using evolutionary models by Burrows et al. and an adopted age of 2-10 Gyr, we derive a mass estimate of 50$\pm$20 M$_{Jup}$ for this object.Comment: 13 pages, 2 figures, 2 tables, accepted by ApJ

Posthospitalization outcomes after extracorporeal membrane oxygenation (ECMO) for COVID-19

BACKGROUND: Critical illness from COVID-19 is associated with prolonged hospitalization and high mortality rates. Extracorporeal membrane oxygenation is used for refractory severe acute respiratory distress syndrome in COVID-19 with outcomes comparable to other indications for extracorporeal membrane oxygenation. However, long-term functional outcomes have yet to be fully elucidated. METHODS: We performed a retrospective chart review of 24 consecutive patients who required extracorporeal membrane oxygenation due to COVID-19 associated severe acute respiratory distress syndrome and survived to hospital discharge. After hospitalization, we contacted patients and administered the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 tool to assess longer-term outcomes. We abstracted demographics, clinical course, outcomes, and disposition variables from the electronic medical record. Descriptive statistical analysis was used on the retrospective data collection. RESULTS: Inpatient data were analyzed for 24 patients, and 21 of 24 (88%) patients completed the Patient-Reported Outcomes Measurement Information System tool at an average of 8.8 months posthospitalization. At hospital discharge, 62.5% of patients had ongoing oxygen requirements (nasal cannula, trach collar, or mechanical ventilation); 70.8% were discharged to a location other than home. However, at the time of follow-up, only 9.5% of patients required supplemental oxygen, all tracheostomies had been removed, and all patients resided at home. Patients reported relatively high levels of global physical function, and though there was a high reported incidence of fatigue, overall pain scores were low. CONCLUSION: Long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from coronavirus disease 2019 are promising. Extracorporeal membrane oxygenation therapy may confer morbidity benefits in patients with coronavirus disease and remains a valuable modality with excellent functional outcomes and preserved quality of life for survivors

Secondary Overtriage of Trauma Patients to a Central Hospital in Malawi

Introduction: Secondary overtriage (OT) is the unnecessary transfer of injured patients between facilities. In low- and middle-income countries (LMICs), which shoulder the greatest burden of trauma globally, the impact of wasted resources on an overburdened system is high. This study determined the rate and associated characteristics of OT at a Malawian central hospital. Methods: A retrospective analysis of prospectively collected data from January 2012 through July 2017 was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Patients were considered OT if they were discharged alive within 48 h without undergoing a procedure, and were not severely injured or in shock on arrival. Factors evaluated for association with OT included patient demographics, injury characteristics, and transferring facility information. Results: Of 80,915 KCH trauma patients, 15,422 (19.1%) transferred from another facility. Of these, 8703 (56.2%) were OT. OT patients were younger (median 15, IQR: 6–31 versus median 26, IQR: 11–38, p < 0.001). Patients with primary extremity injury (5308, 59.9%) were overtriaged more than those with head injury (1991, 51.8%) or torso trauma (1349, 50.8%), p < 0.001. The OT rate was lower at night (18.9% v 28.7%, p < 0.001) and similar on weekends (20.4% v 21.8%, p = 0.03). OT was highest for penetrating wounds, bites, and falls; burns were the lowest. In multivariable modeling, risk of OT was greatest for burns and soft tissue injuries. Conclusions: The majority of trauma patients who transfer to KCH are overtriaged. Implementation of transfer criteria, trauma protocols, and interhospital communication can mitigate the strain of OT in resource-limited settings