Pediatric intestinal obstruction in Malawi: characteristics and outcomes

Abstract Background Intestinal obstruction (IO) is a common pediatric surgical emergency in sub-Saharan Africa with high morbidity and mortality, but little is known about its etiopathogenesis in Malawi. Methods Retrospective analysis of patients seen from February 2012 to June 2014 at Kamuzu Central Hospital in Lilongwe, Malawi (n = 3,407). Pediatric patients with IO were analyzed (n = 130). Results Overall, 57% of patients were male with a mean age of 3.5 ± 4.1 years. A total of 52% of patients underwent operative intervention. The overall mortality rate was 3%. Leading causes of IO were Hirschprung's 29%, anorectal malformation 18%, and intussusception 4%. Neonates and patients with congenital causes of IO underwent surgery less frequently than infants and/or children and patients with acquired causes, respectively. These groups also demonstrated increased number of days from admission to surgery. Conclusions Increasing pediatric-specific surgical education and/or training and expanding access to resources may improve mortality after IO in poor medical communities within sub-Saharan Africa

Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa

Traumatic injuries account for the greatest portion of global surgical burden particularly in low-and middle-income countries (LMICs). To assess effectiveness of a developing trauma system, we hypothesize that there are survival differences between direct and indirect transfer of trauma patients to a tertiary hospital in sub Saharan Africa

Colostomy as a bridge to definitive pediatric surgical care: A sub-Saharan African experience

Available data, however, points to a wide variety of surgical conditions, with the majority falling into three major diagnostic categories, injuries, congenital anomalies, and surgical infections.1 In Africa, children constitute more than half the population.2 Despite high patient volume, very few dedicated pediatric surgeons are available, with only one pediatric surgeon to approximately two million children in Africa, compared with 1:100,000 in North America.3 Owing to this dearth of pediatric surgical workforce, surgical disease in children is not often managed, and if managed, is predominantly managed by a general surgeon who may lack familiarity with complex pediatric surgical procedures. There is little information in the literature regarding the clinical indications for pediatric patients receiving colostomies, complications associated with colostomies, and colostomy reversal rates in sub-Saharan Africa. [...]the aim of this study is to describe the characteristics and outcomes of patients receiving colostomies in a sub-Saharan African setting. [...]during our study period, there were only four patients who returned for reversal of their colostomy, with two colostomy takedowns and two pull-through procedures, with an average of 261.3 ± 288.1 days till reversal (range 36 to 654 days)

The role of the anatomy of the sigmoid colon in developing sigmoid volvulus: A case-control study

Sigmoid volvulus is a common condition throughout much of the world. To this date, there are no adequately controlled clinical trials examining the role of anatomy in sigmoid volvulus. Therefore, the objective of this study was to determine if the anatomic dimensions of the sigmoid colon differ in sigmoid volvulus compared to controls. This prospective case–control study was conducted at Kamuzu Central Hospital, Lilongwe, Malawi. Cases included individuals 18 years or older with surgically confirmed sigmoid volvulus, while controls included individuals undergoing surgery for reasons unrelated to the descending or sigmoid colon, or rectum. Intraoperative measurements of the sigmoid colon were taken, including mesosigmoid root width and mesosigmoid length. A total of 26 cases and 12 controls were enrolled. When compared to controls, the mesosigmoid of cases had a greater length and maximal width; however, mesosigmoid root width was similar between groups. These findings support the assertion that sigmoid volvulus is due to a long and wide mesosigmoid that rotates on a constant mesosigmoid root width. This is the first adequately controlled trial examining anatomy in sigmoid volvulus and provides strong evidence that refines prior hypotheses regarding the anatomic basis of sigmoid volvulus

An observational study addressing the anatomic basis of mesosigmoidopexy as a rational treatment of non-gangrenous sigmoid volvulus

Sigmoid volvulus is a common cause of bowel obstruction.We describe mesosigmoidopexy, an accepted surgical technique for the management of non-gangrenous sigmoid volvulus, and provide anatomic correlations supporting the therapy. Mesosigmoidopexy should be considered as a rational alternative to resection and anastomosis when operating on non-gangrenous sigmoid volvulus

Human papillomavirus in head and neck squamous cell carcinoma: A descriptive study of histologically confirmed cases at Kamuzu Central Hospital in Lilongwe, Malawi

Background: Head and neck squamous cell carcinoma (HNSCC) is common in sub-Saharan Africa, but the aetiologic contribution of human papillomavirus (HPV) is not well established.Methods: We assessed HNSCC cases for HPV using p16 immunohistochemistry (IHC) in Malawi. Associations between p16 IHC and tumour site, behavioural risk factors, demographic characteristics, and HIV status were examined.Results: From 2010 to 2014, 77 HNSCC cases were identified. Mean age was 52 years, 50 cases (65%) were male, and 48 (62%) were in the oropharynx (OP) or oral cavity (OC). HIV status was known for 35 patients (45%), with 5 (14%) HIV-infected. Substance use was known for 40 patients (52%), with 38% reporting any tobacco and 31% any alcohol. Forty-two cases (55%) had adequate tissue for p16 IHC, of which seven (17%) were positive, including 22% of OP/OC tumours.Conclusions: Despite high cervical cancer burden, HPV-associated HNSCC is not very common in Malaw

Complications and 3-month outcomes of children with hydrocephalus treated with ventriculoperitoneal shunts in Malawi

OBJECTIVE Hydrocephalus is the most common pediatric neurosurgical condition, with a high prevalence in low- and middle-income countries. Untreated, hydrocephalus leads to neurological disability or death. The epidemiology and outcomes of hydrocephalus treated by ventriculoperitoneal (VP) shunts in Sub-Saharan Africa are not well defined and vary by region. The aim of the present study was to examine the mortality and morbidity rates and predictors of mortality in children treated by VP shunt placement for hydrocephalus at Kamuzu Central Hospital in Lilongwe, Malawi. METHODS This is a prospective study of 100 consecutive children presenting with hydrocephalus who were treated with VP shunt placement from January 2015 to August 2017. Demographics, nutritional status, maternal characteristics, developmental delay, shunt complications, readmissions, and in-hospital and 3-month mortality data were collected. Multivariate logistic regression was used to identify predictors of death within 3 months of surgery. RESULTS Overall, 46% of participants were female, with an average age of 5.4 ± 3.7 months at the time of surgery. The majority of patients were term deliveries (87.8%) and were not malnourished (72.9%). Only 10.8% of children were diagnosed with meningitis before admission. In-hospital and 3-month mortality rates were 5.5% and 32.1%, respectively. The only significant association with mortality was maternal age, with older maternal age demonstrating decreased odds of 3-month mortality (OR 0.9, 95% CI 0.8–1.0, p = 0.045). CONCLUSIONS Surgical management of hydrocephalus with VP shunts portends a high mortality rate in Malawi. The association of younger maternal age with mortality is likely a proxy for social determinants, which appear to contribute as much to mortality as patient factors. VP shunting is inadequate as a sole surgical management of hydrocephalus in resource-limited settings

Pediatric Surgical Care in Lilongwe, Malawi: Outcomes and Opportunities for Improvement

Background: One of the objectives of the Millennium Development Goals is to improve child health. We describe the burden of pediatric surgical disease at a tertiary hospital in Malawi

Early results of integrated malaria control and implications for the management of fever in under-five children at a peripheral health facility: a case study of Chongwe rural health centre in Zambia

<p>Abstract</p> <p>Background</p> <p>Zambia has taken lead in implementing integrated malaria control so as to attain the National Health Strategic Plan goal of "reducing malaria incidence by 75% and under-five mortality due to malaria by 20% by the year 2010". The strategic interventions include the use of long-lasting insecticide-treated nets and indoor residual spraying, the use of artemisinin-based combination therapies (ACT) for the treatment of uncomplicated malaria, improving diagnostic capacity (both microscopy and rapid diagnostic tests), use of intermittent presumptive treatment for pregnant women, research, monitoring and evaluation, and behaviour change communication. Financial barriers to access have been removed by providing free malaria prevention and treatment services.</p> <p>Methods</p> <p>Data involving all under-five children reporting at the health facility in the first quarter of 2008 was evaluated prospectively. Malaria morbidity, causes of non-malaria fever, prescription patterns treatment patterns and referral cases were evaluated</p> <p>Results</p> <p>Malaria infection was found only in 0.7% (10/1378), 1.8% (251378) received anti-malarial treatment, no severe malaria cases and deaths occurred among the under-five children with fever during the three months of the study in the high malaria transmission season. 42.5% (586/1378) of the cases were acute respiratory infections (non-pneumonia), while 5.7% (79/1378) were pneumonia. Amoxicillin was the most prescribed antibiotic followed by septrin.</p> <p>Conclusion</p> <p>Malaria related OPD visits have reduced at Chongwe rural health facility. The reduction in health facility malaria cases has led to an increase in diagnoses of respiratory infections. These findings have implications for the management of non-malaria fevers in children under the age of five years.</p

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication