The role of endoscopy after upper gastrointestinal bleeding in sub-Saharan Africa: A prospective observational cohort study

BackgroundUpper gastrointestinal (UGI) bleed is a common surgical disease in sub-Saharan Africa where there is often a lack of diagnostic and interventional adjuncts such as endoscopy. This study sought to characterize the role of endoscopy in management of acute UGI bleeding.Materials and MethodsThis is a prospective observational analysis of adults presenting with an UGI bleed to a tertiary center in Lilongwe, Malawi, over two years. Patients were classified as having no endoscopy, diagnostic endoscopy, or endoscopy with variceal banding. Bivariate, survival analysis, and logistic regression analyses were used to compare intervention cohorts.Results293 patients were included with 49 patients (16.7%) receiving endoscopy with banding, 65 (22.2%) patients receiving diagnostic endoscopy only, and 179 (61.1%) receiving no endoscopy. Upon survival analysis comparing to the no endoscopy group, cox hazard modelling showed an adjusted hazard ratio over 30 days of 0.12 (95% CI 0.02, 0.88, p=0.038) for the endoscopic banding group and a hazard ratio of 0.39 (95% CI 0.13, 1.16, p=0.090) for the diagnostic endoscopy only group. Physical exam findings consistent with cirrhosis and decreasing age were independent predictors of an endoscopic diagnosis of variceal bleeding.ConclusionEsophagogastric varices are a common cause of UGI bleeding in sub-Saharan Africa and can be predicted with age and physical exam findings. Endoscopy with variceal banding has a survival benefit for patients presenting with acute UGI bleed even with relatively low utilization. Appropriately triaging patients with likely variceal bleeding and improving endoscopy capacity would likely have a significant impact on mortality

Elderly Trauma in Sub-Saharan Africa

The world is aging rapidly but it is unclear how the world's growing older population will affect health care systems in low or middle-income countries. One area of concern is traumatic injury, which is endemic at all ages, with older patients suffering worse outcomes compared to younger patients. Consequently, traumatic injury in the elderly is an emerging public health issue in resource-poor environments. Unfortunately, there is a dearth of data on the characteristics and extent of this problem in sub-Saharan Africa. This study has two aims. First, it will describe what data are available on elderly trauma in sub-Saharan Africa and access the quality of published studies. Second, it will describe the characteristics and outcomes of traumatic injury in the elderly from a tertiary trauma center in sub-Saharan Africa.Master of Public Healt

Outcomes of stab wounds presenting to Kamuzu Central Hospital in Malawi

IntroductionInjuries are a leading cause of morbidity and mortality worldwide, necessitating that we understand the local burden of injury to improve injury-related trauma care and patient outcomes. The characteristics, outcomes, and risk factors for mortality following stab wounds in Malawi are poorly delineated.MethodsThis is a retrospective, descriptive analysis of patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, with stab wounds from February 2008 to May 2018. Univariate and bivariate analyses were performed to compare patient and injury characteristics based on mortality. We performed Poisson multivariate regression to predict the factors that increase the relative risk of mortality. Results During the study, 32,297 patients presented with assault. Of those patients, 2,352 (7.3%) presented with stab wounds resulting in a 3.2% (n=74) overall mortality. The majority of wounds were to the head or cervical spine (n=1,043, 44.6%), while injuries to the chest (n=319, 13.7%) were less frequent. We found an increased relative risk of mortality in patients who presented with an injury to the chest (RR 3.95, 95% CI 1.79-8.72, p=0.001) and who were brought in by the police (RR 33.24, 95% CI 11.23–98.35, p<0.001). ConclusionIn this study, stab wounds accounted for 7.3% of all assault cases, with a 3.2% mortality. Though the commonest site of stab was the head, wounds to the chest conferred the highest relative risk of mortality. A multifaceted approach to reducing mortality is needed. Incorporating training of first responders in basic life support, including the police, may reduce stab-related mortality

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

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

Variations in injury characteristics among paediatric patients following trauma: A retrospective descriptive analysis comparing pre-hospital and in-hospital deaths at Kamuzu Central Hospital, Lilongwe, Malawi

Background: Trauma is a major cause of paediatric mortality in sub-Saharan Africa. In absence of pre-hospital care, the injury mechanism and cause of death is difficult to characterise. Injury characteristics of pre-hospital deaths (PHD) versus in-hospital deaths (IHD) were compared.Methods: Using our trauma surveillance database, a retrospective, descriptive analysis of children (<18 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi from 2008 to 2013 was performed. Patient and injury characteristics of pre-hospital and in-hospital deaths were compared with univariate and bivariate analysis.Results: Of 30,462 paediatric trauma patients presenting between 2008 and 2013, 170 and 173 were PHD and IHD, respectively. In PHD and IHD patients mean age was 7.3±4.9 v 5.2±4.3 (p<0.001), respectively. IHD patients were more likely transported via ambulance than those PHD, 51.2% v 8.3% (p<0.001). The primary mechanisms of injury for PHD were road traffic injuries (RTI) (45.8%) and drowning (22.0%), with head injury (46.7%) being the predominant cause of death. Burns were the leading mechanism of injury (61.8%) and cause of death (61.9%) in IHD, with a mean total body surface area involvement of 24.7±16.0%.Conclusions: RTI remains Malawi’s major driver of paediatric mortality. A majority of these deaths attributed to head injury occur prior to hospitalisation; therefore the mortality burden is underestimated if accounting for IHD alone. Death in burn patients is likely due to under-resuscitation or sepsis. Improving pre-hospital care and head injury and burn management can improve injury related paediatric mortality

Burn Injury, Characteristics, and Epidemiology in African American Children in North Carolina

Unintentional injuries, including burns, represent the leading cause of morbidity and mortality for children in the United States. This study seeks to identify trends among African American pediatric burn patients compared to other races with regards to burn characteristics, hospital stay, and type of surgical intervention utilized. This is a retrospective review of all admitted pediatric burn patients (< 18 years old) to a busy, tertiary burn center in North Carolina from 2009 through 2019. We used bivariate analysis to compare patients based on reported race, comparing African Americans to all other races. Modified Poisson regression was used to model the probability of undergoing autologous skin grafting based on African American race, adjusted for potential confounders. To estimate socioeconomic disadvantage, we used the Area Deprivation Index (ADI), which uses factors for the theoretical domains of income, education, employment, and housing quality to rank groups of geographical blocks from lowest level of disadvantage (1) to the highest (100). 4,227 children were admitted to UNC between 2009-2019. The median age was 3 years (IQR 1-8) with a male preponderance at 59.8% (n=2,529). The median TBSA was 2% (IQR 1-5). African American (AA) children were disproportionally represented among pediatric burn patients, comprising 33.7% of all patients, compared to an African American state population of 22.2%. AA patients were more likely to have scald burn injuries compared to other races at 68.5% (n=976) compared to 49.3% (1,382, p<0.001) with both fire and contact injuries less common in AA children. AA patients had a slightly larger TBSA with a median of 3% (IQR 1-6) compared to 2% (IQR 1-5, p<0.001). In the hospital, AA patients had a longer mean length of stay at 5.8 days (SD 13.6) versus 4.9 days (SD 13.8) but were not more likely to be admitted to the ICU with an admission prevalence of 17.1% (n=244) compared to 15.4% (n=430, p=0.13). Compared to other races, African American patients were more likely to have autologous skin grafting at their initial operation, with an adjusted RR of 1.49 (95% CI 1.22-1.82) when controlling for age, Area Deprivation Index (ADI) national rank, TBSA, and burn type. African American children were disproportionately represented among pediatric burn patients, more likely to have scald burn injuries that were slightly bigger compared to patients of other races, had longer hospital stays, and were more likely to have autologous skin grafting upon initial surgical intervention. This research provides important insight into the demographics of pediatric burn patients in North Carolina, as well as data on burn characteristics and medical interventions used for African American patients compared to other races. This information is necessary in order to guide treatment decisions, inform prevention strategies, and accurately assess mortality risk in a vulnerable patient population

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

Timing of early excision and grafting following burn in sub-Saharan Africa

This study sought to establish appropriate timing of burn wound excision and grafting in a resource-poor setting in sub-Saharan Africa

The role of ECMO in COVID-19 acute respiratory failure: Defining risk factors for mortality

Background Veno-venous extracorporeal membrane oxygenation (VV ECMO) utilization increased substantially during the COVID-19 pandemic, but without patient selection criteria. Methods We conducted a retrospective review of all adult patients with COVID-19-associated ARDS placed on VV ECMO at our institution from April 2020 through June 2022. Results 162 patients were included (n = 95 Pre-Delta; n = 58 Delta; n = 9 Omicron). The frequency of ECMO duration greater than three weeks was variable by pandemic period (17% pre-Delta, 41% Delta, 22% Omicron, p = 0.003). In-hospital mortality was 60.5%. Age ≥50 years (RR 1.28, 95% CI 1.01, 1.62), ≥7 days of respiratory support (1.39, 95% CI 1.05, 1.83) and pre-cannulation renal failure requiring dialysis (RR 1.42, 95% CI 1.13, 1.78) were associated with mortality. Conclusions In this cohort of VV ECMO patients with COVID-19, older age, a longer duration of pre-ECMO respiratory support, and pre-ECMO renal failure all increased the risk of mortality by approximately 30%