Measuring Geospatial and Longitudinal Trends in Malaria Using National Health Surveillance Data in Malawi

Malaria is a significant cause of morbidity and mortality in Malawi, accounting for 30% of outpatient visits. Children report the highest rates of disease, but adults are thought to be an important reservoir to sustained transmission due to persistent asymptomatic infection. However, national malaria measures have been exclusively estimated through Malaria Indicator Surveys which only offer a regional cross-sectional glance at parasite prevalence among children. Malaria is geographically and temporally heterogeneous, making it necessary to understand local and longitudinal transmission patterns before planning targeted interventions. Long-lasting insecticide treated bed nets (LLINs) are integral to Malawi’s malaria prevention efforts and are allocated to households every 3-years through mass distribution campaigns. Evidence suggests that the maximum protective lifespan of LLINs is 1-3-years, but a national longitudinal evaluation has never been conducted in Malawi.The 2015-2016 Malawi Demographic and Health Survey (MDHS) was a nationally representative household survey of asymptomatic individuals ages 15-54. We analyzed 7,393 survey samples, detecting a P. falciparum prevalence of 31.1%. Protective factors included urbanicity, greater wealth, higher education, and lower environmental temperatures, but living in a household with a bed net and sleeping under an LLIN were not protective against infection. To assess clinical malaria over time, we used District Health Information Software 2 (DHIS2) data from January 2018 to June 2020, capturing monthly aggregate reports of confirmed cases from 711 health facilities across Malawi. We found that risk varied at the health facility level and was highest from January to May. Risk decreased one high transmission season following distribution of 10.7 million LLINs and rebounded after two seasons, indicating that LLINs only have a lifespan of 1-2-years. Piperonyl butoxide-treated nets performed better than pyrethroid-treated nets and LLIN effectiveness varied geographically.Our findings demonstrate a high parasite prevalence among adults, highlighting this population as an important reservoir to sustained transmission. LLINs have a 1-2-year lifespan and insecticide type influences effectiveness. Use of molecular surveillance to supplement ongoing passive data collection creates a natural opportunity to track how large-scale changes affect malaria over time and provide valuable insight to the Malawi Ministry of Health as they plan future interventions. Doctor of Philosoph

Pattern of adult intestinal obstruction at Tenwek hospital, in south-western Kenya

Introduction: acute mechanical intestinal obstruction (IO) is one of the leading causes of surgical admissions in most emergency departments worldwide. The causes of IO vary significantly depending on geographical location. The aim of this study was to identify the etiology, management and outcomes of patients with acute mechanical IO presenting in south-western Kenya. Methods: a 4 year (November 2009–October 2013) retrospective review of all adult patients admitted with acute mechanical IO at Tenwek Hospital in Bomet, Kenya. Results: a total of 303 male and 142 female patients, presented with acute mechanical IO during the study period. Mean patient age was 40.6 years (range 17-91), with peak  incidence in those aged 31-40 years. The foremost signs and symptoms were abdominal pain (89.4%), abdominal tenderness (81.6%), vomiting (78%), abdominal distension (65.4%) and constipation (50.8%). Sigmoid volvulus (25.6%), adhesions (23.1%), small bowel volvulus (21.3%), and ileo-sigmoid knotting (8.5%) were the leading causes of IO. Laparotomy was undertaken in 361 (81.1%) cases, with bowel gangrene noted in 112 (30.4%). The overall morbidity and mortality rates were 15% and 4.5% respectively. Patients with gangrenous bowel at laparotomy had a higher morbidity rate (22.3% vs 9.6%, P=.001), a higher mortality rate (9.8% vs 3.2%, P=.02) and a longer duration of stay (9.9 days vs 7.6 days,  P=.0001) compared to those with viable bowel. Conclusion: the most common causes of IO in this study were sigmoid volvulus, adhesions, small bowel volvulus and ileo-sigmoid knotting. Presence of bowel gangrene was associated with higher morbidity and mortality rates

Role of Rigid Endoscopic Detorsion in the Management of Sigmoid Volvulus

Introduction: Sigmoid Volvulus (SV) is a common cause of bowel obstruction in Africa, affecting a relatively young and healthy population. There has been little research regarding the use of endoscopic detorsion in the management of SV from East Africa. The aim of this study was to determine the outcome of patients with SV managed by endoscopic detorsion at a single institution over a 9 year period.Methods: A retrospective review of all patients admitted with SV at Tenwek Hospital in Bomet, Kenya from January 2006 to October 2014 was done. Data were collected on demographics, clinical presentation, operative findings, management, and outcome.Results: There were 159 cases with a mean age of 41.1 years (range 15-87). Rigid endoscopic detorsion was attempted in 125 (79%) patients. The success, early recurrence, and mortality rate for rigid endoscopic detorsion was 79%, 6%, and 0% respectively. Eleven (13%, n=99) patients declined surgery after successful endoscopic detorsion, while 87 patients had semi-elective surgery, an average of 3.5 days post detorsion. Sixty patients had emergency surgery, with gangrenous bowel noted in 43 (72%) cases. Patients undergoing emergency surgery had a higher morbidity rate (27% vs. 5%, p=0.0002), and a higher mortality rate (12% vs. 0, p=0.002) compared to those having semi-elective surgery due to the presence of gangrenous bowel.Conclusion: Rigid endoscopic detorsion is appropriate in the initial management of any stable patient with clinical and radiological features suggestive of sigmoid volvulus without features of peritonitis.Keywords: Sigmoid Volvulus, Endoscopic Detorsion, Rigid Sigmoidoscopy, Outcomes

Ileo-sigmoid knotting: a review of 61 cases in Kenya

Introduction: Ileo-sigmoid knotting (ISK) is a rare cause of bowel obstruction in which the ileum twists around the sigmoid colon. It is associated with rapid bowel gangrene and a high mortality rate. Little has been published about this condition in Kenya. The objective was to determine the presentation, management, and outcome of patients with ISK. Methods: A seven year (January 2008-December 2014) retrospective chart review of patients managed for ISK at Tenwek Hospital in Bomet, Kenya. Results: A total of 61 cases were identified, with a mean age of 35.8 years (range 2-68), and mean symptom duration of 1.6 days (range 3 hours-7 days). Gangrene was noted to involve both the ileum and colon in 45 patients, the ileum only in 9 patients, and the sigmoid colon only in one. Resection and primary anastomosis was carried out in most cases of gangrenous ileum (48/54, 89%) and gangrenous sigmoid colon (34/46, 74%), while resection and stoma was performed in 8 patients with gangrenous colon. Death occurred in 7 (11.5%) patients due to severe sepsis and multisystem organ failure. Morbidities were noted in 15 (24.6%) patients, including surgical site infection (8, 13.1%), respiratory insufficiency (4, 6.6%), fascial dehiscence (3, 4.9%) and anastomotic leak (2, 3.2%). The mean duration of hospitalization was 8.3 days (range 1-26). Conclusion: In this review, though retrospective in nature, ISK was noted to have high rates of bowel gangrene. In the appropriate setting, resection and primary anastomosis can be safely carried out in most cases of gangrenous colon.Pan African Medical Journal 2016; 2

The Spectrum of Paediatric Intestinal Obstruction in Kenya

Introduction: Intestinal obstruction (IO) occurs when there is impedance to the flow of intestinal contents due to a congenital or acquired pathology, and is a common paediatric surgical emergency. This study aimed to assess the pattern and outcome of paediatric IO in western Kenya. Methods: A retrospective review of all recorded cases of mechanical IO in patients aged 15 years or below admitted at Tenwek Hospital between January 2009 and December 2013. Results: The cohort included a total of 217 children (130 boys and 87 girls). The mean age was 6.7 years (range: newborn-15 years), with most (65, 30%) cases aged 1-3 years. Vomiting (161, 74.2%), abdominal pain (152, 70%), abdominal tenderness (113, 52.1%), constipation (111, 51.2%), and abdominal distension (104, 47.9%) were the predominant signs and symptoms. The most common causes of IO were ascariasis (96, 44.2%), adhesions (34, 15.7%), and intussusception (30, 13.8%). Intussusception was the leading cause of IO in children aged≤1 year, ascariasis in children aged 1-5 and 6-10 years, and adhesions in children aged 11-15 years. Operative management was undertaken in 120 (55.3%) cases with 39 (32.5%) of these having gangrenous bowel. The overall mortality rate was 5%. Conclusion: The most common causes of mechanical bowel obstruction in this series were ascariasis, adhesions, and intussusception. Ascariasis remains a significant cause of paediatric IO in this region, thus public education, improved sanitation and deworming campaigns may be helpful in reducing the worm burden.Pan African Medical Journal 2016; 2

Metrics and Evaluation Tools for Patient Engagement in Healthcare Organization- and System-Level DecisionMaking: A Systematic Review

Abstract Background: Patient, public, consumer, and community (P2C2) engagement in organization-, community-, and systemlevel healthcare decision-making is increasing globally, but its formal evaluation remains challenging. To define a taxonomy of possible P2C2 engagement metrics and compare existing evaluation tools against this taxonomy, we conducted a systematic review. Methods: A broad search strategy was developed for English language publications available from January 1962 through April 2015 in PubMed, Embase, Sociological Abstracts, PsycINFO, EconLit, and the gray literature. A publication was excluded if: (1) the setting was not healthcare delivery (ie, we excluded non-health sectors, such as urban planning; research settings; and public health settings not involving clinical care delivery); (2) the P2C2 engagement was episodic; or (3) the concept of evaluation or possible evaluation metrics were absent. To be included as an evaluation tool, publications had to contain an evaluative instrument that could be employed with minimal modification by a healthcare organization. Results: A total of 199 out of 3953 publications met exclusion and inclusion criteria. These were qualitatively analyzed using inductive content analysis to create a comprehensive taxonomy of 116 possible metrics for evaluating P2C2 engagement. 44 outcome metrics were grouped into three domains (internal, external, and aggregate outcomes) that included six subdomains: impact on engagement participants, impact on services provided by the healthcare organization, impact on the organization itself, influence on the broader public, influence on population health, and engagement cost-effectiveness. The 72 process metrics formed four domains (direct process metrics; surrogate process metrics; aggregate process metrics; and preconditions for engagement) that comprised sixteen subdomains. We identified 23 potential tools for evaluating P2C2 engagement. The identified tools were published between 1973-2015 and varied in their coverage of the taxonomy, methodology used (qualitative, quantitative, or mixed), and intended evaluators (organizational leaders, P2C2 participants, external evaluators, or some combination). Parts of the metric taxonomy were absent from all tools. Conclusions: By comprehensively mapping potential outcome and process metrics as well as existing P2C2 engagement tools, this review supports high-quality P2C2 engagement globally by informing the selection of existing evaluation tools and identifying gaps where new tools are needed

Azathioprine Maintenance Therapy to Prevent Relapses in Autoimmune Pancreatitis

Steroids are used to induce remission in autoimmune pancreatitis (AIP). Low-dosage steroid therapy or immunosuppressant (IMs) has been proposed as maintenance therapy to prevent AIP relapse. Few and conflicting data have been published on the efficacy of azathioprine (AZA) in preventing AIP relapse. The aim of this study was to evaluate the indication and efficacy of AZA as maintenance therapy to prevent disease relapse in AIP