Joint replacement in Zambia: A review of Hip & Knee Replacement surgery done at the Zambian-Italian Orthopaedic Hospital

Background: Incidence of major joint replacement surgery is on the rise in Africa but this trend has not been matched by proper audits in the form of National Joint Registries.Objective: This paper presents the short-term findings from a joint replacement register started at the Zambian-Italian Orthopaedic Hospital (ZIOH) in Lusaka and compares the variables entered in this register with those captured in the Malawian National Joint Register for purposes of synchronizing these in the near future in the East, Central and Southern African region .Methods: Data captured by the different variables entered into the Joint Register covering the pre-op, intra-op and post-op period of all total hip and knee replacement surgery done at the ZIOH from 1998 to 2010 was entered into a spreadsheet after verification with individual patient medical records. This was then imported into spss for analysis yielding the following results.Results: 44 total hips and seven total knee replacement operations were done on 46 patients, 59% of which were female and 41% male. The average age was 58 years. The HIV sero-status of 86.3% was unknown. 36 (70.6%) of the patients had primary osteoarthritis as the diagnosis with pain and joint stiffness being the indication for surgery. Three consultants and one senior registrar did the operations mainly using the Hardinge approach to the hip. 43 (84.3%) were primary Total Hip replacement with only one revision. The 28mm hip head size was the commonest fitted with most patients, 48 (94.1%) being functionally mobile at six weeks post operation.Conclusion: This audit clearly shows a rising trend of major joint replacement over the years and highlights the gaps in variables entered into the ZIOH joint register such as HIV status. It also helps us recognize the need for setting up a National Joint Register that is comparable to others that have been set up in the region such as is the case in Malawi which is key in improving orthopaedic training and patient care.Keywords: Joint replacement, National Joint Register, HI

Service evaluation to establish the sensitivity, specificity and additional value of broad-range 16S rDNA PCR for the diagnosis of infective endocarditis from resected endocardial material in patients from eight UK and Ireland hospitals

Infective endocarditis (IE) can be diagnosed in the clinical microbiology laboratory by culturing explanted heart valve material. We present a service evaluation that examines the sensitivity and specificity of a broad-range 16S rDNA polymerase chain reaction (PCR) assay for the detection of the causative microbe in culture-proven and culture-negative cases of IE. A clinical case-note review was performed for 151 patients, from eight UK and Ireland hospitals, whose endocardial specimens were referred to the Microbiology Laboratory at Great Ormond Street Hospital (GOSH) for broad-range 16S rDNA PCR over a 12-year period. PCR detects the causative microbe in 35/47 cases of culture-proven IE and provides an aetiological agent in 43/69 cases of culture-negative IE. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the 16S rDNA PCR assay were calculated for this series of selected samples using the clinical diagnosis of IE as the reference standard. The values obtained are as follows: sensitivity = 67 %, specificity = 91 %, PPV = 96 % and NPV = 46 %. A wide range of organisms are detected by PCR, with Streptococcus spp. detected most frequently and a relatively large number of cases of Bartonella spp. and Tropheryma whipplei IE. PCR testing of explanted heart valves is recommended in addition to culture techniques to increase diagnostic yield. The data describing the aetiological agents in a large UK and Ireland series of culture-negative IE will allow future development of the diagnostic algorithm to include real-time PCR assays targeted at specific organisms

Endoscopic third ventriculostomy and choroid plexus cauterization in childhood hydrocephalus in Zambia

Background: Endoscopic third ventriculostomy (ETV) and Choroid Plexus Cauterization (CPC) have been recommended as reliable surgical options in developing countries for childhood hydrocephalus owing to reported shunt failures in shunt dependency.Objective: To evaluate outcomes of the ETV and ETV-CPC procedures as surgical options for selected forms of hydrocephalus in Zambia.Methods: Between 2007 and 2010, 131 children with hydrocephalus underwent the ETV or ETVCPC procedures at Beit Cure Hospital (BCH) and were eligible for the analysis. Failed ETV was defined as cases that needed subsequent surgical procedures within 6 months of operation.Results: A total number of 110 (84%) children underwent ETV-CPC and 21 (16%) had ETV alone. The overall success rate was 74%, whereas ETV-CPC was 76% and ETV alone was 62% (p < 0.0001). ETV success rate was more likely with children aged one year and above (p < 0.06) and with non-post infectious hydrocephalus (p < 0.29). Age and etiology were not significantly associated with the outcomes.Conclusions: Endoscopic third ventriculostomy is a safe, reliable and effective option for selected forms of hydrocephalus in Zambia. The combination of ETV and CPC was more effective than ETV alone. It is highly recommended that such services be extended to other referral hospitals as options to shunt placement, especially in cases where access for treatment failure is likely to be delayed.Keywords: Hydrocephalus, endoscopic third ventriculostomy, choroid plexus cauterization, Outcomes, Physiotherapy, Zambi

What happens to ART-eligible patients who do not start ART? Drop out between screening and ART initiation: a cohort study in Karonga, Malawi

BACKGROUND: Routine ART programme statistics generally only provide information about individuals who start treatment. We aimed to investigate the outcome of those who are eligible but do not start ART in the Malawi programme, factors associated with this dropout, and reasons for not starting treatment, in a prospective cohort study.METHODS: Individuals having a first screening visit at the ART clinic at Karonga District Hospital, northern Malawi, between September 2005 and July 2006 were interviewed. Study follow-up to identify treatment outcomes was conducted at the clinic and in the community. Logistic regression models were used to identify factors associated with dropout before ART initiation among participants identified as clinically eligible for ART.RESULTS: 88 participants eligible for ART at their first screening visit (out of 633, 13.9%) defaulted before starting ART. Participants with less education, difficulties in dressing, a more delayed ART initiation appointment, and mid-upper arm circumference (MUAC) < 22 cm were significantly less likely to have visited the clinic subsequently. Thirty-five (58%) of the 60 participants who defaulted and were tracked at home had died, 21 before their ART initiation appointment.CONCLUSIONS: MUAC and reported difficulties in dressing may provide useful screening indicators to identify sicker ART-eligible individuals at high risk of dropping out of the programme who might benefit from being brought back quickly or admitted to hospital for observation. Individuals with less education may need adapted health information at screening. Deaths of ART-eligible individuals occurring prior to ART initiation are not included in routine programme statistics. Considering all those who are eligible for ART as a denominator for programme indicators would help to highlight this vulnerable group, in order to identify new opportunities for further improving ART programmes

The impact of HIV on morbidity and mortality from tuberculosis in sub-Saharan Africa: a study of rural Malawi and review of the literature

Since the mid-1980s tuberculosis (TB) case numbers and HIV seroprevalence have both risen sharply in sub-Saharan Africa. Estimates for the relative risk of TB in those infected with HIV have ranged from less than five to more than 20. The proportion of TB cases attributable to HIV (the population attributable fraction) has been calculated for several populations but is difficult to interpret if no account is taken of the age and sex distribution of the cases. In a rural area of Malawi we have studied the proportion of TB attributable to HIV over time. Nearly 40 per cent of smear-positive TB cases in this rural area of Malawi can now be attributed directly to HIV. The actual effect of HIV on TB is even greater than this because increased case numbers increase transmission of tuberculosis infection to both HIV-infected and non-infected sections of the population. We compare our findings with others from sub-Saharan Africa and discuss reasons for the differences, and methodological issues in interpretatio

Phenotypic variation in fruit and seed morphology of Adansonia digitata L (Baobab) in five selected wild populations in Malawi

Adansonia digitata L (Baobab) is widely distributed throughout Sub-Saharan Africa stretching from Senegal to Sudan, and from Ethiopia to Natal. Information of phenotypic and genetic variation is a prerequisite for the domestication and improvement of baobab fruits from the wild. A study was done to determine within and between provenance variability in fruit and seed characteristics of five populations selected from four silvicultural zones and assess whether morphometric traits could delineate populations from different zones into land races. Fruits were characterized from 55 trees representing a wide geographical range. Six fruit traits and three individual seed traits were assessed. Results showed highly significant differences (P≤0.001) in fruit, pulp, and seed weight, fruit length and width, number of seed, individual seed weight, seed length and width within and between populations. Mean fruit weight ranged from 125.8 ± 3.25 g to 162.9 ± 3.25 g, seed weight ranged from 38.6 ± 2.5 g to 66 ± 2.01g and pulp weight ranged from 28.7 ± 1.33 g to 41.4 ± 1.33 g. Single seed weight showed pronounced evidence of divergence of populations into ecotypes. The rich diversity found between and within populations is important for domestication purposes and tree improvement through selection and breeding. All populations could be used for seed source but distribution should be consciously done recognizing existence of races.Universities of Mzuzu and Stellenbosch and University of Pretoria.http://www.springer.com/life+sci/forestry/journal/1045

Genetic variation among and within provenances of Adansonia digitata L. (Baobab) in seed germination and seedling growth from selected natural populations in Malawi

Baobab (Adansonia digitata L) trees have a wide variety of subsistence and economic values across sub-Saharan Africa. Knowledge of the genetic variation within and between the species is essential for management and designing domestication, improvement and conservation strategies. Fifty-nine half-sib families were evaluated in the nursery to determine the genetic variation and control within and between the populations from four silvicultural zones. Seed germination and seven seedling growth parameters were assessed. Total phenotypic variance, family variance, within family variance, individual narrow sense heritability, and additive genetic coefficient of variation (AGCV) were derived from observed and expected mean squares. There were highly significant differences in seed germination, plant height, root collar diameter, number of leaves, shoot height and diameter, tuber diameter and weight. Provenance variation in germination ranged from 46.7 ±3.3% to 68.7±3.3% while tree –to- tree variation ranged from 6.3±8.6% to 95.5±8.6%. Coefficient of variation in seedling growth variables ranged from 18.6% to 43.6%. Individual narrow sense heritabilities (h2) ranged from 0.07 to 0.71. AGCV ranged from 3.21% to 14.67%. Morphological traits showed that mainland populations were genetically distant from the island one. High and moderate additive genetic control of traits and AGCV show the potential that Baobab can also respond well to tree improvement. High phenotypic variation found in the study offers an opportunity to effect selection of superior attributes at both provenance and individual tree-to-tree level.Universities of Mzuzu and Stellenbosch.http://www.agronomy-journal.org/hb201