Effect of in-hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi

Background: In sub-Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care-seeking by patients. Delays in treatment can result from delayed presentation (pre-hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in-hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD. Methods: Utilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD. Results: Of 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night-time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment. Conclusion: IHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed

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

Orbital Separation Amplification in Fragile Binaries with Evolved Components

The secular stellar mass-loss causes an amplification of the orbital separation in fragile, common proper motion, binary systems with separations of the order of 1000 A.U. In these systems, companions evolve as two independent coeval stars as they experience negligible mutual tidal interactions or mass transfer. We present models for how post-main sequence mass-loss statistically distorts the frequency distribution of separations in fragile binaries. These models demonstrate the expected increase in orbital seapration resulting from stellar mass-loss, as well as a perturbation of associated orbital parameters. Comparisons between our models and observations resulting from the Luyten survey of wide visual binaries, specifically those containing MS and white-dwarf pairs, demonstrate a good agreement between the calculated and the observed angular separation distribution functions.Comment: 37 pages, 13 figure

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 Nuclear Sigma Term in the Skyrme Model: Pion-Nucleus Interaction

The nuclear sigma term is calculated including the nuclear matrix element of the derivative of the NN interaction with respect to the quark mass, $m_q\frac{\partial V_{NN}}{\partial m_q}$. The NN potential is evaluated in the skyrmion-skyrmion picture within the quantized product ansatz. The contribution of the NN potential to the nuclear sigma term provides repulsion to the pion-nucleus interaction. The strength of the s-wave pion-nucleus optical potential is estimated including such contribution. The results are consistent with the analysis of the experimental data.Comment: 16 pages (latex), 3 figures (eps), e-mail: [email protected] and [email protected]

Evaluation of Complications and Weight Outcomes in Pediatric Cerebral Palsy Patients With Gastrostomy Tubes

Background: Feeding difficulties are common in children with cerebral palsy (CP). The goal of this study was to examine pediatric CP patients undergoing gastrostomy tube (G tube) placement and assess the association between patient characteristics and weight after 3 months, 6 months, and 1 year. Methods: This was a retrospective study of all pediatric patients with CP who received a G tube placement between April 2014 and December 2017 at a single institution. Bivariate analysis was used to examine association between patient characteristics and the primary outcome of improvement in weight Z score at 3, 6, and 12 months. Results: Of 63 patients who received a G tube, 81% had an increase in Z score at 3 months, 44% at 6 months, and 64% at 12 months. By 12 months, factors associated with a positive Z score change included moderate and severe malnutrition, lack of prior G tube, and fewer comorbidities. The majority (69.8%) of patients experienced complications. Seven (11%) patients died, with only 1 death related to G tube placement. Discussion: The use of G tubes in CP patients resulted in an increase in an improvement in nutritional status for the majority of patients over the course of a year. Although most complications were minor, patients had a high complication rate and frequently visited the emergency department, highlighting the need for standardized education and follow-up among this patient population

Secondary Overtriage of Trauma Patients to a Central Hospital in Malawi

Introduction: Secondary overtriage (OT) is the unnecessary transfer of injured patients between facilities. In low- and middle-income countries (LMICs), which shoulder the greatest burden of trauma globally, the impact of wasted resources on an overburdened system is high. This study determined the rate and associated characteristics of OT at a Malawian central hospital. Methods: A retrospective analysis of prospectively collected data from January 2012 through July 2017 was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Patients were considered OT if they were discharged alive within 48 h without undergoing a procedure, and were not severely injured or in shock on arrival. Factors evaluated for association with OT included patient demographics, injury characteristics, and transferring facility information. Results: Of 80,915 KCH trauma patients, 15,422 (19.1%) transferred from another facility. Of these, 8703 (56.2%) were OT. OT patients were younger (median 15, IQR: 6–31 versus median 26, IQR: 11–38, p < 0.001). Patients with primary extremity injury (5308, 59.9%) were overtriaged more than those with head injury (1991, 51.8%) or torso trauma (1349, 50.8%), p < 0.001. The OT rate was lower at night (18.9% v 28.7%, p < 0.001) and similar on weekends (20.4% v 21.8%, p = 0.03). OT was highest for penetrating wounds, bites, and falls; burns were the lowest. In multivariable modeling, risk of OT was greatest for burns and soft tissue injuries. Conclusions: The majority of trauma patients who transfer to KCH are overtriaged. Implementation of transfer criteria, trauma protocols, and interhospital communication can mitigate the strain of OT in resource-limited settings

Demonstration of the temporal matter-wave Talbot effect for trapped matter waves

We demonstrate the temporal Talbot effect for trapped matter waves using ultracold atoms in an optical lattice. We investigate the phase evolution of an array of essentially non-interacting matter waves and observe matter-wave collapse and revival in the form of a Talbot interference pattern. By using long expansion times, we image momentum space with sub-recoil resolution, allowing us to observe fractional Talbot fringes up to 10th order.Comment: 17 pages, 7 figure

Azimuthal anisotropy and correlations in p+p, d+Au and Au+Au collisions at 200 GeV

We present the first measurement of directed flow ($v_1$) at RHIC. $v_1$ is found to be consistent with zero at pseudorapidities $\eta$ from -1.2 to 1.2, then rises to the level of a couple of percent over the range $2.4 < |\eta| < 4$. The latter observation is similar to data from NA49 if the SPS rapidities are shifted by the difference in beam rapidity between RHIC and SPS. Back-to-back jets emitted out-of-plane are found to be suppressed more if compared to those emitted in-plane, which is consistent with {\it jet quenching}. Using the scalar product method, we systematically compared azimuthal correlations from p+p, d+Au and Au+Au collisions. Flow and non-flow from these three different collision systems are discussed.Comment: Quark Matter 2004 proceeding, 4 pages, 3 figure