Carlos Varela

Delivery of operative pediatric surgical care by physicians and non-physician clinicians in Malawi

BACKGROUND Specialized pediatric surgeons are unavailable in much of sub-Saharan Africa. Delegating some surgical tasks to non-physician clinical officers can mitigate the dependence of a health system on highly skilled clinicians for specific services. METHODS We performed a case-control study examining pediatric surgical cases over a 12 month period. Operating surgeon was categorized as physician or clinical officer. Operative acuity, surgical subspecialty, and outcome were then compared between the two groups, using physicians as the control. RESULTS A total of 1186 operations were performed on 1004 pediatric patients. Mean age was 6 years (±5) and 64% of patients were male. Clinical officers performed 40% of the cases. Most general surgery, urology and congenital cases were performed by physicians, while most ENT, neurosurgery, and burn surgery cases were performed by clinical officers. Reoperation rate was higher for patients treated by clinical officers (17%) compared to physicians (7.1%), although this was attributable to multiple burn surgical procedures. Physician and clinical officer cohorts had similar complication rates (4.5% and 4.0%, respectively) and mortality rates (2.5% and 2.1%, respectively). DISCUSSION Fundamental changes in health policy in Africa are imperative as a significant increase in the number of surgeons available in the near future is unlikely. Task-shifting from surgeons to clinical officers may be useful to provide coverage of basic surgical care.

CHOP Chemotherapy for Aggressive Non-Hodgkin Lymphoma with and without HIV in the Antiretroviral Therapy Era in Malawi.

There are no prospective studies of aggressive non-Hodgkin lymphoma (NHL) treated with CHOP in sub-Saharan Africa. We enrolled adults with aggressive NHL in Malawi between June 2013 and May 2015. Chemotherapy and supportive care were standardized, and HIV+ patients received antiretroviral therapy (ART). Thirty-seven of 58 patients (64%) were HIV+. Median age was 47 years (IQR 39–56), and 35 (60%) were male. Thirty-five patients (60%) had stage III/IV, 43 (74%) B symptoms, and 28 (48%) performance status ≥2. B-cell NHL predominated among HIV+ patients, and all T-cell NHL occurred among HIV- individuals. Thirty-one HIV+ patients (84%) were on ART for a median 9.9 months (IQR 1.1–31.7) before NHL diagnosis, median CD4 was 121 cells/μL (IQR 61–244), and 43% had suppressed HIV RNA. HIV+ patients received a similar number of CHOP cycles compared to HIV- patients, but more frequently developed grade 3/4 neutropenia (84% vs 31%, p = 0.001), resulting in modestly lower cyclophosphamide and doxorubicin doses with longer intervals between cycles. Twelve-month overall survival (OS) was 45% (95% CI 31–57%). T-cell NHL (HR 3.90, p = 0.017), hemoglobin (HR 0.82 per g/dL, p = 0.017), albumin (HR 0.57 per g/dL, p = 0.019), and IPI (HR 2.02 per unit, p<0.001) were associated with mortality. HIV was not associated with mortality, and findings were similar among patients with diffuse large B-cell lymphoma. Twenty-three deaths were from NHL (12 HIV+, 11 HIV-), and 12 from CHOP (9 HIV+, 3 HIV-). CHOP can be safe, effective, and feasible for aggressive NHL in Malawi with and without HIV.

Development of a ratio of emergent to total hernia repairs as a surgical capacity metric

INTRODUCTION Non-communicable diseases including surgical conditions are gaining attention in developing countries. Despite this there are few metrics for surgical capacity. We hypothesized that (a) the ratio of emergent to total hernia repairs (E/TH) would correlate with per capita health care expenditures for any given country, and (b) the E/TH is easy to obtain in resource-poor settings. METHODS We performed a systematic review to identify the E/TH for as many countries as possible (Prospero registry CRD42013004645). We screened 1285 English language publications since 1990; 23 met inclusion criteria. Primary data was also collected from Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. A total of 13 countries were represented. Regression analysis was used to determine the correlation between per capita health care spending and the E/TH. RESULTS There is a strong correlation between the log values of the ratio emergent to total groin hernias and the per capita health care spending that is robust across country income levels (R(2) = 0.823). Primary data from KCH was easily obtained and demonstrated a similar correlation. CONCLUSIONS The ratio of emergent to total groin hernias is a potential measure of surgical capacity using data that is easily attainable. Further studies should validate this metric against other accepted health care capacity indicators. Systematic review registered with Prospero (CRD42013004645).

The role of seizure disorders in burn injury and outcome in Sub-Saharan Africa.

Patients with epilepsy have higher incidence and severity of burn injury. Few studies describe the association between epilepsy and burns in low-income settings, where epilepsy burden is highest. The authors compared patients with and without seizure disorder in a burn unit in Lilongwe, Malawi. The authors conducted a retrospective study of patients admitted to the Kamuzu Central Hospital burn ward from July 2011 to December 2012. Descriptive analysis of patient characteristics and unadjusted and adjusted analyses of risk factors for mortality were conducted for patients with and without seizure disorder. Prevalence of seizure disorder was 10.7% in the study population. Adults with burns were more likely to have seizure disorder than children. Flame injury was most common in patients with seizure disorder, whereas scalds predominated among patients without seizure disorder. Whereas mortality did not differ between the groups, mean length of stay was longer for patients with seizure disorder, 42.1 days vs 21.6 days. Seizure disorder continues to be a significant risk factor for burn injury in adults in Malawi. Efforts to mitigate epilepsy will likely lead to significant decreases in burns among adults in Sub-Saharan Africa and must be included in an overall burn prevention strategy in our environment.

Pediatric surgical care in Lilongwe, Malawi: Outcomes and opportunities for improvement

BACKGROUND One of the objectives of the Millennium Development Goals is to improve child health. We describe the burden of pediatric surgical disease at a tertiary hospital in Malawi. METHODS We conducted a retrospective analysis of a pediatric surgery database at Kamuzu Central Hospital in Malawi for the calendar year 2012. Variables included patient demographics, admission diagnosis, primary surgery and outcome. RESULTS A total of 1170 pediatric patients aged 0-17 years were admitted to the surgical service during the study period. The mean age was 6.9 years, and 62% were male. Trauma was the most common indication for admission (51%, n = 596), and 67% (n = 779) of all patients were managed non-operatively. Neonates and patients managed non-operatively had a significantly increased risk of mortality. CONCLUSION Only a third of patients admitted to the pediatric surgery service underwent surgery. More than half of patients with congenital anomalies did not undergo surgical intervention. Importantly, patients who underwent surgery had a survival advantage.

Mortality After Peritonitis in Sub-Saharan Africa: An Issue of Access to Care

Mortality After Peritonitis in Sub-Saharan Africa: An Issue of Access to Care There is a lack of access to emergency surgical care in developing countries despite a burden of surgical disease.1 Health care systems are overwhelmed by the high volume of patients who need acute care and by insufficient capacity because of a lack of appropriate prehospital care, surgery-capable clinicians, and basic health care delivery infrastructures.2 Compared with high-income countries where mortality from peritonitis is less than 5%, mortality in this resource-poor setting is nearly 20%.1,3 These patients are particularly susceptible because of a lack of the prerequisite surgical infrastructure, which includes prompt triage and diagnosis, early transfer to a higher level of care, timely surgical intervention, and critical care services.4 This study identifies outcomes of patients with peritonitis and factors that contribute to mortality.

Application of SIRS criteria to a paediatric surgical population in Malawi

INTRODUCTION Little is known regarding systemic inflammatory response syndrome (SIRS) criteria and mortality in developing countries. We evaluated the utility of the SIRS criteria to predict death among a paediatric surgical population in Lilongwe, Malawi. METHODS Age, SIRS variables (temperature, heart rate, systolic blood pressure, respiratory rate and leucocyte count), diagnosis, surgical procedure and outcome were analysed for paediatric surgical patients during 2012. Age-specific criteria for SIRS variables were then applied to the data. RESULTS Using published SIRS criteria, temperature was the only variable that correlated with mortality. When norms for an African population were used, leucocyte count also correlated with mortality. DISCUSSION With the exception of temperature, published SIRS criteria were not predictive of mortality. Leucocyte count became predictive of death using norms specific to an African population. SIRS and its component data are a worthwhile area of future prospective research in developing countries.

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.

Road traffic collisions in Malawi: Trends and patterns of mortality on scene

Background Worldwide, 90% of injury deaths occur in low- and middle-income countries (LMIC). Road traffic collisions (RTCs) are increasingly common and result in more death and disability in the developing world than in the developed world. We aimed to examine the pre-hospital case fatality rate from RTCs in Malawi. Material and Methods A retrospective study was performed utilizing the Malawian National Road Safety Council (NRSC) registry from 2008–2012. The NRSC data were collected at the scene by police officers. Victim, vehicle, and environmental factors were used to describe the characteristics of fatal collisions. Case fatality rate was defined as the number of fatalities divided by the number of people involved in RTCs each year. Logistic regression analysis was used to determine predictors of crash scene fatality. Results A total of 11,467 RTCs were reported by the NRSC between 2008 and 2012. Of these, 34% involved at least one fatality at the scene. The average age of fatalities was 32 years and 82% were male. Drivers of motor vehicles had the lowest odds of mortality following RTCs. Compared to drivers; pedestrians had the highest odds of mortality (OR 39, 95% CI 34, 45) followed by bicyclists (OR 26, 95% CI 22, 31). The average case fatality rate was 17% /year, and showed an increased throughout the study period. Conclusions RTCs are a common cause of injury in Malawi. Approximately one-third of RTCs involved at least one death at the scene. Pedestrians were particularly vulnerable, exhibiting very high odds of mortality when involved in a road traffic collision. We encourage the use of these data to develop strategies in LMIC countries to protect pedestrians and other road users from RTCs.

Untreated surgical conditions in Malawi: A randomised cross-sectional nationwide household survey

Background Noncommunicable diseases, such as surgical conditions have received little attention from public health planners in low income countries (LIC) like Malawi. Though increasingly recognised as a growing global health problem, the burden of surgical pathologies and access to surgical care has not been adequately identified in many LIC. Information on the spectrum and burden of surgical disease in Malawi is important to uncover the unmet need for surgery and for planning of the National Health Service. Methods This was a multistage random cluster sampling national survey. Households were selected from clusters using probability proportional to size method. 1448 households and 2909 interviewees were analysed. The Surgeons Overseas Assessment of Surgical need (SOSAS) tool was used to collect data. This electronic tablet based questionnaire tool included general information and a dual personalised head to toe inquiry on surgical conditions. The general information included number of household members, and inquired on any death within the past twelve months, and if any of the deaths in the family had a suspected surgical condition leading to that death. Data was collected by specially trained third year medical students. Results Out of 1480 selected households, 1448 (98%) agreed to participate, with 2909 interviewed individuals included in the study. The median household size was 6 individuals (range 1 – 47). Median age of interviewed persons was 35 years (range 0.25 – 104 years). 1027 out of 2909 (35%) of the interviewed people reported to be living with a condition requiring surgical consultation or intervention, whereas 146 of 616 (24%) of the total deaths reported to have occurred in the preceding 12 months were reported to have died from a surgically related condition. Most individuals did not seek health care due to lack of funds for transportation to the health facility. Only 3.1% of those that reported a surgical condition had surgical intervention. Conclusions There is a large unmet need for surgical care in Malawi. A third of the population is living with a condition needing surgical consultation or intervention, and a quarter of all deaths are potentially avoidable with surgery. Urgent scale up of surgical services and training are needed to reduce this huge gap in public health planning in the country.