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

Spatial and temporal diversity in genomic instability processes defines lung cancer evolution

PMCID: PMC4636050.-- et al.Spatial and temporal dissection of the genomic changes occurring during the evolution of human non-small cell lung cancer (NSCLC) may help elucidate the basis for its dismal prognosis.We sequenced 25 spatially distinct regions from seven operable NSCLCs and found evidence of branched evolution, with driver mutations arising before and after subclonal diversification. There was pronounced intratumor heterogeneity in copy number alterations, translocations, and mutations associated with APOBEC cytidine deaminase activity. Despite maintained carcinogen exposure, tumors from smokers showed a relative decrease in smoking-related mutations over time, accompanied by an increase in APOBEC-associated mutations. In tumors from former smokers, genome-doubling occurred within a smoking-signature context before subclonal diversification, which suggested that a long period of tumor latency had preceded clinical detection. The regionally separated driver mutations, coupled with the relentless and heterogeneous nature of the genome instability processes, are likely to confound treatment success in NSCLC.E.B. is a Rosetrees Trust fellow; M.J.H. has a Cancer Research UK fellowship; N.Mu. received funding from the Rosetrees Trust; M.G. is funded by the UK Medical Research Council; I.V. is funded by Spanish Ministerio de Economía y Competitividad subprograma Ramón y Cajal; R.C.R. and D.M.R. are partly funded by the Cambridge Biomedical Research Centre and Cancer Research UK Cancer Centre; P.V.L. is a postdoctoral researcher of the Research Foundation—Flanders (FWO); S.M.J. is a Wellcome Senior Fellow in Clinical Science; and C.S. is a senior Cancer Research UK clinical research fellow and is funded by Cancer Research UK, the Rosetrees Trust, European Union Framework Programme 7 (projects PREDICT and RESPONSIFY, ID:259303), the Prostate Cancer Foundation, the European Research Council and the Breast Cancer Research Foundation. This research is supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre.Peer Reviewe

Case Report: A patient with severe peritonitis

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Proteomic evaluation of citrate-coated silver nanoparticles toxicity in Daphnia magna

Recent decades have seen a strong increase in the promise and uses of nanotechnology. This is correlated with their growing release in the environment and there is concern that nanomaterials may endanger ecosystems. Silver nanoparticles (AgNPs) have some of the most varied applications, making their release into the environment unavoidable. In order to assess their potential toxicity in aquatic environments, the acute toxicity of citrate-coated AgNPs to Daphnia magna was measured and compared to that of AgNO3. AgNPs were found to be ten times less toxic by mass than silver ions, and most of this toxicity was removed by ultracentrifuging. At the protein level, the two forms of silver had different impacts. Both increased protein thiol content, while only AgNP increased carbonyl levels. In 2DE of samples labelled for carbonyls, no feature was significantly affected by both compounds, indicating different modes of toxicity. Identified proteins showed functional overlap between the two compounds: vitellogenins (vtg) were present in most features identified, indicating their role as a general stress sensor. In addition to vtg, hemoglobin levels were increased by the AgNP exposure while 14-3-3 protein (a regulatory protein) carbonylation levels were reduced by AgNO3. Overall, this study confirms the previously observed lower acute toxicity of AgNPs, while demonstrating that the toxicity of both forms of silver follow somewhat different biologic pathways, potentially leading to different interactions with natural compounds or pollutants in the aquatic environment

Road traffic collisions in Malawi: Trends and patterns of mortality on scene

Background: Worldwide, 90% of injury deaths occur in low- and middle-income countries (LMIC). Road traffic collisions (RTCs) are increasingly common and result in more death and disability in the developing world than in the developed world. We aimed to examine the prehospital case fatality rate from RTCs in Malawi.Material and Methods: A retrospective study was performed utilizing the Malawian National Road Safety Council (NRSC) registry from 2008-2012. The NRSC data were collected at the scene by police officers. Victim, vehicle, and environmental factors were used to describe the characteristics of fatal collisions. Case fatality rate was defined as the number of fatalities divided by the number of people involved in RTCs each year. Logistic regression analysis was used to determine predictors of crash scene fatality.Results: A total of 11,467 RTCs were reported by the NRSC between 2008 and 2012. Of these, 34% involved at least one fatality at the scene. The average age of fatalities was 32 years and 82% were male. Drivers of motor vehicles had the lowest odds of mortality following RTCs. Compared to drivers; pedestrians had the highest odds of mortality (OR 39, 95% CI 34, 45) followed by bicyclists (OR 26, 95% CI 22, 31). The average case fatality rate was 17% / year, and showed an increased throughout the study period.Conclusions: RTCs are a common cause of injury in Malawi. Approximately one-third of RTCs involved at least one death at the scene. Pedestrians were particularly vulnerable, exhibiting very high odds of mortality when involved in a road traffic collision. We encourage the use of these data to develop strategies in LMIC countries to protect pedestrians and other road users from RTCs

Delivery of operative pediatric surgical care by physicians and non-physician clinicians in Malawi

Specialized pediatric surgeons are unavailable in much of sub-Saharan Africa. Delegating some surgical tasks to non-physician clinical officers can mitigate the dependence of a health system on highly skilled clinicians for specific services

Mortality after peritonitis in sub-saharan Africa: An issue of access to care

There is a lack of access to emergency surgical care in developing countries despite a burden of surgical disease. Health care systems are overwhelmed by the high volume of patients who need acute care and by insufficient capacity because of a lack of appropriate prehospital care, surgery-capable clinicians, and basic health care delivery infrastructures. Compared with high-income countries where mortality from peritonitis is less than 5%, mortality in this resource-poor setting is nearly 20%. These patients are particularly susceptible because of a lack of the prerequisite surgical infrastructure, which includes prompt triage and diagnosis, early transfer to a higher level of care, timely surgical intervention, and critical care services. This study identifies outcomes of patients with peritonitis and factors that contribute to mortality

Practical and ethical challenges of a North-South partnership

INTRODUCTION The Departments of Surgery at the University of North Carolina (UNC) and Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, formed a partnership of service, training, and research in 2008. We report a case of recurrent pancreatitis leading to pancreatic necrosis treated at KCH. PRESENTATION OF CASE A 42 year-old male presented to KCH with his fourth episode of abdominal pain, nausea and vomiting. He had tachycardia, guarding, rebound tenderness, and free fluid on abdominal ultrasonography. He underwent laparotomy and had fat saponification with pancreatic necrosis. A large drain was placed, he was given antibiotics, and he recovered. He had normal lipids, no gallstones, and did not consume alcohol. He was encouraged to seek further evaluation with endoscopic retrograde cholangiopancreatography or computed tomography in South Africa, however this was prohibitively expensive. DISCUSSION This case illustrates the limitations that are often faced by surgeons visiting developing countries. What we consider standard resources and treatment algorithms in managing necrotizing pancreatitis in developed countries (such as serum lipase and percutaneous interventions) were not available. CONCLUSION Visiting surgeons and trainees must be both familiar with local resource limitations and aware of the implications of such limitations on patient care. To support training and promote advances in health care, local surgeons and trainees should understand optimal treatment strategies regardless of their particular resource limitations. North-South partnerships are an excellent means to uphold our professional obligation to humanity, promote health care as a right, and shape the future of health care in developing countries

Parametric Resonance in Immersed Elastic Boundaries

In this paper, we investigate the stability of a fluid-structure interaction problem in which a flexible elastic membrane immersed in a fluid is excited via periodic variations in the elastic stiffness parameter. This model can be viewed as a prototype for active biological tissues such as the basilar membrane in the inner ear, or heart muscle fibers immersed in blood. Problems such as this, in which the system is subjected to internal forcing through a parameter, can give rise to "parametric resonance." We formulate the equations of motion in two dimensions using the immersed boundary formulation. Assuming small amplitude motions, we can apply Floquet theory to the linearized equations and derive an eigenvalue problem whose solution defines the marginal stability boundaries in parameter space. The eigenvalue equation is solved numerically to determine values of fiber stiffness and fluid viscosity for which the problem is linearly unstable. We present direct numerical simulations of the fluid-structure interaction problem (using the immersed boundary method) that verify the existence of the parametric resonances suggested by our analysis

The Inter-Relationship Between Employment Status and Interpersonal Violence in Malawi: A Trauma Center Experience

Introduction: As a proportion of the overall population, sub-Saharan Africa (SSA) has the highest youth demographic, composing 60% of Africa’s unemployed. With the worsening economic crisis in low- and middle-income countries, unengaged youth are susceptible to gang violence and anti-government demonstrations, resulting in political instability. Methods: We performed a retrospective review of the Kamuzu Central Hospital Trauma Registry from 2008–2018. All adult patients (>14 years) injured by interpersonal violence (IPV) were included. Age was categorized as 15–24 (youth), 25–45, and >45 years. A bivariate analysis (IPV versus unintentional injury), and Poisson multivariable analysis were performed to identify factors increasing the risk of IPV. Results: During the study, 87,338 trauma patients presented; 30,532 (35.0%) were injured following IPV. Patients injured following IPV (28 years, IQR 23–34) were younger than those unintentionally injured (30 years, IQR 23–39, p 45 years (RR 1.72, 1.66–1.79), and those injured at night (RR 2.18, 95% CI 2.14–2.23) had increased the risk of being victims of IPV. Conclusion: In Malawi, there is an interrelationship between unemployment and IPV, particularly in the youth population. Given impending demographic realities, government and non-government organizations should prioritize youth employment to help defer political instability in vulnerable nation-states