Etiology of major limb amputations at a tertiary care centre in Malawi

IntroductionAmputations in low- and middle-income countries (LMICs) represent an important cause of disability and economic hardship. LMIC patients are young and suffer from preventable causes, such as trauma and trauma-related infections. We herein studied the etiology in amputations in a Malawian tertiary care hospital over a 9-year period.Methods Operative and anaesthesia logs at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, were reviewed for 2008–2016. Baseline demographic and clinical variables and type of amputation performed were collected. Only major limb amputations, defined as above or below the knee, above or below the elbow, and above the wrist, were included in this study. Results A total of 610 patients underwent 630 major amputations during the study period. Of these, 170 (27%) patients were female, and the median age of the cohort was 39 (interquartile range [IQR] 25–55). Of these patients, 345 (54.8%) had infection or gangrene recorded among the indications for amputation, 203 (32.2%) had trauma, 94 (14.9%) had cancer and 67 (10.6%) had documented diabetes. Women underwent diabetes-related amputations more often than men (37 out of 67, or 56.1%), and were significantly younger when their amputations were due to diabetes (median age 48 vs 53 years old, P=0.004) or trauma (median age 21 vs 30 years old, P=0.02). The commonest operative procedures were below the knee amputations, at 271 (43%), and above the knee amputations, at 213 (33.8%). ConclusionAmputations in Malawi affect primarily the young, in the most economically productive time of their lives, in contrast to amputees in high-income countries. Preventable causes, such as infection and trauma, lead to the majority of amputations. These etiologies represent an important primary prevention target for public health efforts in LMICs.

Characteristics and outcomes of traumatic spinal cord injury in a low-resource setting

Spinal cord injury (SCI) is relatively rare and affects an estimated 15–40 per 1 million people globally. All patients admitted from October 2016 to June 2017 at Kamuzu Central Hospital, Malawi with a spinal column injury were retrospectively studied. Out of 1442 patients, 46 had vertebral column injury, and half of these had neurological deficit. The most common mechanism of injury was road traffic crash (45.7%), and cervical SCIs were the most common (41.3%). The overall mortality was 15.2%, thus demonstrating devastating morbidity and mortality. Owing to the latter, and the relative lack of operative facilities, primary prevention remains the most effective way to attenuate the tragedy of SCIs

Epidemiology, Management, and Functional Outcomes of Traumatic Brain Injury in Sub-Saharan Africa

Background Trauma accounts for 4.7 million deaths each year, with an estimated 90% of these occurring in low- and middle-income countries (LMICs). Approximately half of trauma-related deaths are caused by central nervous system injury. Because a thorough understanding of traumatic brain injury (TBI) in LMICs is essential to mitigate TBI-related mortality, we established a clinical and radiographic database to characterize TBI in our low-income setting. Methods This is a review of prospectively collected data from Kamuzu Central Hospital, a tertiary care center in the capital of Malawi. All patients admitted from October 2016 through May 2017 with a history of head trauma, altered consciousness, and/or radiographic evidence TBI were included. We performed descriptive statistics, a Cox regression analysis, and a survival analysis. Results There were 280 patients who met inclusion criteria; of these, 80.5% were men. The mean age was 28.8 ± 16.3 years. Median Glasgow Coma Scale (GCS) score was 12 (interquartile range, 8–15). Road traffic crashes constituted the most common injury mechanism (60.7%). There were 148 (52.3%) patients who received a computed tomography scan, with the most common findings being contusions (26.1%). Of the patients, 88 (33.0%) had severe TBI, defined as a GCS score ≤8, of whom 27.6% were intubated and 10.3% received tracheostomies. Overall mortality was 30.9%. Of patients who survived, 80.1% made a good recovery. Female sex was protective, and the only significant predictor of poor functional outcome was presence of severe TBI (hazard ratio, 2.98; 95% confidence interval, 1.79–4.95). Conclusions TBI represents a significant part of the global neurosurgical burden of disease. Implementation of proven in-hospital interventions for these patients is critical to attenuate TBI-related morbidity and mortality

The effect of anatomic location of injury on mortality risk in a resource-poor setting

Introduction Injury is a significant cause of death, with approximately 4.7 million people mortalities each year. By 2030, injury is predicted to be among the top 20 causes of death worldwide. We sought to characterize and compare the mortality probability in trauma patients in a resource-poor setting based on anatomic location of injury. Methods We performed a retrospective analysis of prospectively collected data using the trauma database at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. We included all adult trauma patients (≥16years) admitted between 2011 and 2015. We stratified patients according to anatomic location of injury, and used descriptive statistics to compare characteristics and management of each group. Bivariate analysis by mortality was done to determine covariates for our adjusted model. A Cox proportional hazard model was performed, using upper extremity injury as the baseline comparator. Descriptive statistics were used to describe the trend in incidence and mortality of head and spine injuries over five years. Results Of the 76,984 trauma patients who presented to KCH from 2011 to 2015, 49,126 (63.8%) were adults, and 8569 (17.4%) were admitted. The most common injury was to the head or spine, seen in 3712 patients (43.6%). The highest unadjusted hazard ratio for mortality was in head and spine injury patients, at 3.685 (95% CI = 2.50–5.44), which increased to 4.501 (95% CI = 2.78–7.30) when adjusted for age, sex, injury severity, transfer status, injury mechanism, and surgical intervention. Abdominal trauma had the second highest adjusted hazard of mortality, at 3.62 (95% CI = 1.92–6.84) followed by thoracic trauma (HR = 1.3621, 95% CI = 0.49–3.56). Conclusion In our setting, head or spine injury significantly increases the hazard of mortality significantly compared to all other anatomic injury locations. The prioritization of timely operative and non-operative head injury management is imperative. The development of head injury units may help attenuate trauma- related mortality in resource poor settings

Paediatric road traffic injuries in Lilongwe, Malawi: an analysis of 4776 consecutive cases

This was a retrospective review of all children aged ≤16 who were treated in the casualty department at the central hospital in Lilongwe, Malawi, between 1 January 2009 and 31 December 2015. A total of 4776 children were treated for road traffic injuries (RTIs) in the study period. There was an increase in incidence from 428 RTIs in 2009 to a maximum of 834 in 2014. Child pedestrians represented 53.8% of the injuries, but 78% of deaths and 71% of those with moderate to severe head injuries. Pedestrians were mostly injured by cars (36%) and by large trucks, buses and lorries (36%). Eighty-four (1.8%) children were brought in dead, while 40 (0.8%) children died in the casualty department or during their hospital stay. There has been a drastic increase of RTIs in children in Lilongwe, Malawi. Child pedestrians were most affected, both in terms of incidence and severity

The effect of pre-existing malnutrition on pediatric burn mortality in a sub-Saharan African burn unit

Introduction Nutritional status predicts burn outcomes in the developed world, but its effect on burn mortality in the developing world has not been widely studied. In sub Saharan Africa, burn is primarily a disease of children, and the majority of children in sub-Saharan Africa are malnourished. We therefore sought to determine the prevalence and effect of malnutrition on burn mortality at our institution. Methods This is a retrospective review of children aged 0–5, with anthropomorphic measurements available, who were admitted to our burn unit from July 2011 to May 2016. Age-adjusted Z scores were calculated for height, weight, weight for height, and mid-upper arm circumference (MUAC). Following bivariate analysis, we used logistic regression to construct a fully adjusted model of predictors of mortality. Results Of the 1357 admitted patients, 839 (61.2%) were aged 0–5. Of those, 512 (62.9%) had one or more anthropomorphic measurements available, and were included in the analysis. 54% were male, and the median age was 28 months. The median TBSA was 15%, with a majority of burns caused by scalds (77%). Mortality was 16%. Average Z-score for any of the indicators of malnutrition was −1.45 ± 1.66. TBSA (OR: 1.08, 95% CI: 1.06, 1.11), decreasing Z-score (OR: 1.19, 95% CI: 1.00, 1.41), and flame burn (OR: 2.51, 95% CI: 1.40, 4.49) were associated with an increase in mortality. Conclusion Preexisting malnutrition in burn patients in sub-Saharan Africa increases odds of mortality after controlling for significant covariates. Survival of burn patients in this region will not reach that of the developed world until a strategy of aggressive nutritional support is implemented in this population

Anatomic Location and Mechanism of Injury Correlating with Prehospital Deaths in Sub-Saharan Africa

Introduction: Trauma is a large contributor to morbidity and mortality in developing countries. We sought to determine which anatomic injury locations and mechanisms of injury predispose to prehospital mortality in Malawi to help target preventive and therapeutic interventions. We hypothesized that head injury would result in the highest prehospital mortality. Methods: This was a retrospective analysis of all trauma patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from 2008 to 2015. Independent variables included baseline characteristics, anatomic location of primary injury, mechanism of injury, and severity of secondary injuries. Multivariable logistic regression was used to assess the effect of primary injury location and injury mechanism on prehospital death, after adjusting for confounders. Effect measure modification of the primary injury site/prehospital death relationship by injury mechanism (stratified into intentional and unintentional injury) was assessed. Results: Of 85,806 patients, 701 died in transit (0.8%). Five hundred and five (72%) of these patients sustained a primary head injury. After adjustment, head injury was the anatomic location most associated with prehospital death (OR 11.81 (95% CI 6.96–20.06, p < 0.0001). The mechanisms of injury most associated with prehospital death were gunshot wounds (OR 38.23, 95% CI 17.66–87.78, p < 0.0001) and pedestrian hit by vehicle (OR 2.62, 95% CI 1.92–3.55, p < 0.0001). Among head injury patients, the odds of prehospital mortality were higher with unintentional injuries. Conclusions: Head injuries are the most common causes of prehospital death in Malawi, while pedestrians hit by vehicles are the most common mechanisms. In a resource-poor setting, preventive measures are critical in averting mortality

Sex Disparities in Access to Surgical Care at a Single Institution in Malawi

Introduction: There is a paucity of data regarding sex-based disparities in surgical care delivery, particularly in low- and middle-income countries. This study sought to determine whether sex disparities are present among patients presenting with surgical conditions in Malawi. Hypothesis compared to men, fewer women present to Kamuzu Central Hospital (KCH) with peritonitis and have longer delays in presentation for definitive care. Methods: This study performs a retrospective analysis of prospectively collected data of all general surgery patients with peritonitis presenting to KCH in Lilongwe, Malawi, from September 2013 to April 2016. Multivariable linear and logistic regressions were used to assess the effect of sex on mortality, length of stay, operative intervention, complications, and time to presentation. Results: Of 462 patients presenting with general surgery conditions and peritonitis, 68.8% were men and 31.2% were women. After adjustments, women had significantly higher odds of non-operative management when compared to men (OR 2.17, 95%CI 1.30–3.62, P = 0.003), delays in presentation (adjusted mean difference 136 h, 95%CI 100–641, P = 0.05), delays to operation (adjusted mean difference 1.91 days, 95%CI 1.12–3.27, P = 0.02), and longer lengths of stay (adjusted mean difference 1.67 days, 95%CI 1.00–2.80, P = 0.05). There were no differences in complications or in-hospital or Emergency Department mortality. Conclusion: Sex disparities exist within the general surgery population at KCH in Lilongwe, Malawi. Fewer women present with surgical problems, and women experience delays in presentation, longer lengths of stay, and undergo fewer operations. Future studies to determine mortality in the community and driving factors of sex disparities will provide more insight

The Effect of a Surgery Residency Program and Enhanced Educational Activities on Trauma Mortality in Sub-Saharan Africa

Introduction: To address the need for more surgical providers in low-resource settings, a collaboration to create a surgical residency-training program for local Malawian physicians was established in 2009. This study sought to describe the short-term independent effect of a surgical residency program on trauma mortality at a tertiary trauma center in sub-Saharan Africa. Methods: We conducted a retrospective analysis of all patients recorded in the trauma surveillance registry of Kamuzu Central Hospital in Lilongwe, Malawi, from 2009 (three residents) through 2014 (11 residents). Log-binominal regression modeling was used to compare the risk ratio of death compared to the referent year of 2009, when the program was started, after adjusting for relevant covariates. Primary injury type was used as a surrogate for injury severity. Results: In total, 82,534 patients were recorded into the KCH Trauma Registry during the study period. Mean age was 23.1 years (SD 15.7) with a male preponderance (72.1%). Trauma patient volume increased from 8725 patients in 2009 to 15,998 patients in 2014. Each year had a significantly decreased risk of death compared to 2009 when adjusted for primary injury type, age, and gender, with an adjusted risk ratio of 0.73 (95% CI 0.58, 0.90) in 2010 and 0.52 (95% CI 0.43, 0.62) in 2014. Conclusion: The global burden of surgical diseases cannot be attenuated in the presence of an inadequate surgical workforce. After institution of a surgery residency program, adjusted injury-associated mortality decreased each year despite substantial increases in trauma patient volume. In low-resource settings, establishment of a surgical residency program significantly improves trauma-associated outcomes

Etiology of major limb amputations at a tertiary care centre in Malawi

Introduction Amputations in low-and middle-income countries (LMICs) represent an important cause of disability and economic hardship. LMIC patients are young and suffer from preventable causes, such as trauma and trauma-related infections. We herein studied the etiology in amputations in a Malawian tertiary care hospital over a 9-year period. Methods Operative and anaesthesia logs at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, were reviewed for 2008–2016. Baseline demographic and clinical variables and type of amputation performed were collected. Only major limb amputations, defined as above or below the knee, above or below the elbow, and above the wrist, were included in this study. Results A total of 610 patients underwent 630 major amputations during the study period. Of these, 170 (27%) patients were female, and the median age of the cohort was 39 (interquartile range [IQR] 25–55). Of these patients, 345 (54.8%) had infection or gangrene recorded among the indications for amputation, 203 (32.2%) had trauma, 94 (14.9%) had cancer and 67 (10.6%) had documented diabetes. Women underwent diabetes-related amputations more often than men (37 out of 67, or 56.1%), and were significantly younger when their amputations were due to diabetes (median age 48 vs 53 years old, P=0.004) or trauma (median age 21 vs 30 years old, P=0.02). The commonest operative procedures were below the knee amputations, at 271 (43%), and above the knee amputations, at 213 (33.8%). Conclusion Amputations in Malawi affect primarily the young, in the most economically productive time of their lives, in contrast to amputees in high-income countries. Preventable causes, such as infection and trauma, lead to the majority of amputations. These etiologies represent an important primary prevention target for public health efforts in LMICs