Nonoperative Management Versus Laparoscopic Appendectomy in Children: A Cost-Effectiveness Analysis.

INTRODUCTION: Nonoperative management (NOM) of acute appendicitis in the pediatric population is highly debated with uncertain cost-effectiveness. We performed a decision tree cost-effectiveness analysis of NOM versus early laparoscopic appendectomy (LA) for acute appendicitis in children. METHODS: We created a decision tree model for a simulated cohort of 49,000 patients, the number of uncomplicated appendectomies performed annually, comparing NOM and LA. We included postoperative complications, recurrent appendicitis, and antibiotic-related complications. We used the payer perspective with a 1-year time horizon. Model uncertainty was analyzed using a probabilistic sensitivity analysis. Event probabilities, health-state utilities, and costs were obtained from literature review, Healthcare Cost and Utilization Project, and Medicare fee schedules. RESULTS: In the base-case analysis, NOM costs $6530/patient and LA costs $9278/patient on average at 1 y. Quality-adjusted life year (QALY) differences minimally favored NOM compared to LA with 0.997 versus 0.996 QALYs/patient. The incremental cost-effectiveness ratio for NOM over LA was $4,791,149.52/QALY. NOM was dominant in 97.4% of simulations, outperforming in cost and QALYs. A probabilistic sensitivity analysis showed NOM was 99.6% likely to be cost-effective at a willingness-to-pay threshold of $100,000/QALY. CONCLUSIONS: Our model demonstrates that NOM is a dominant strategy to LA over a 1-year horizon. We use recent trial data demonstrating higher rates of early and late NOM failures. However, we also incorporate a shorter length of index hospitalizations with NOM, reflecting a contemporary approach to NOM and ultimately driving cost-effectiveness. Long-term follow-up data are needed in this population to assess the cost-effectiveness of NOM over longer time horizons, where healthcare utilization and recurrence rates may be higher.

Race, area deprivation index, and access to surgical burn care in a pediatric population in North Carolina.

BACKGROUND: Burns represent a leading cause of morbidity and mortality for children. This study explores the intersecting effects of social deprivation and race in pediatric burn patients. METHODS: We performed a retrospective review of all pediatric patients (<18 years old) admitted to a tertiary burn center in North Carolina from 2009 to 2019. We used bivariate analysis to compare patients based on reported race, comparing African Americans (AA) to all others. Modified Poisson regression was used to model the probability of undergoing autologous skin grafting based on AA race. RESULTS: Of 4227 children admitted, AA children were disproportionally represented, comprising 33.7% of patients versus a state population of 22.3%. AA patients had larger %TBSA with a median of 3% (IQR 1-6) compared to 2% (IQR 1-5, p < 0.001) and longer median length of stay at 5.8 days (SD 13.6) versus 4.9 days (SD 13.8). AA patients were more likely to have autologous skin grafting compared to other races, with an adjusted RR of 1.49 (95% CI 1.22-1.83) when controlling for Area Deprivation Index (ADI) national rank, age, %TBSA, and burn type. CONCLUSIONS: AA children were disproportionately represented and had larger burns, even when controlling for ADI. They had longer hospital stays and were more likely to have autologous skin grafting, even accounting for burn size and type. The intersection between social deprivation and race creates a unique risk for AA patients. Further investigation into this phenomenon and factors underlying surgical intervention selection are indicated to inform best treatment practices and future preventative strategies.

Treatment of Acute Severe Asthma Exacerbation with Extracorporeal Membrane Oxygenation and Inhaled Volatile Anesthetic.

Severe asthma affects approximately 1-2% of all asthmatic patients. Acute exacerbations are associated with high mortality in this population. There are many treatment options for asthma exacerbation; however, if these treatments fail, patients can develop progressive hypoxia, hypercarbia, respiratory acidosis, and hemodynamic instability. Extracorporeal membrane oxygenation (ECMO) and inhaled anesthetic both have a role in the management of acute severe refractory asthma exacerbation, though there is limited information about the use of both together. We present the case of a patient with severe asthma who suffered a refractory asthma exacerbation and was successfully managed with veno-venous ECMO and inhaled anesthetic. ECMO and inhaled volatile anesthetic both have a role in the management of severe refractory asthma exacerbations. It is safe and beneficial to use these therapies together and more benefit is noted if initiated early in the course of the patient's illness.

Reallocation of Hospital Resources During COVID-19 Pandemic and Effect on Trauma Outcomes in a Resource-Limited Setting.

BACKGROUND: The COVID-19 pandemic has caused unprecedented disruptions to surgical care worldwide, particularly in low-resource countries. We sought to characterize the association between pre-and intra-pandemic trauma clinical outcomes at a busy tertiary hospital in Malawi. METHODS: We analyzed trauma patients that presented to Kamuzu Central Hospital in Lilongwe, Malawi, from 2011 through July 2021. Burn patients were excluded. We compared patients based on whether they presented before or during the pandemic (defined as starting March 11, 2020, the date of the official WHO designation). We used logistic regression modeling to estimate the adjusted odds ratio of death based on presentation. RESULTS: A total of 137,867 patients presented during the study period, with 13,526 patients during the pandemic. During the pandemic, patients were more likely to be older (mean 28 vs. 25 years, p < 0.001), male (79 vs. 74%, p < 0.001), and suffer a traumatic brain injury (TBI) as their primary injury (9.7 vs. 4.9%, p < 0.001). Crude trauma-associated mortality was higher during the pandemic at 3.7% vs. 2.1% (p < 0.001). The odds ratio of mortality during the pandemic compared to pre-pandemic presentation was 1.28 (95% CI 1.06, 1.53) adjusted for age, sex, initial AVPU score, transfer status, injury type, and mechanism. CONCLUSIONS: During the pandemic, adjusted trauma-associated mortality significantly increased at a tertiary trauma center in a low-resource setting despite decreasing patient volume. Further research is urgently needed to prepare for future pandemics. Potential targets for improvement include improving pre-hospital care and transportation, planning for intensive care utilization, and addressing nursing shortages.

Validating the danger of vehicular protective devices and bowel injury.

INTRODUCTION: Protective devices such as seat belts and airbags have improved the safety of motor vehicle occupants, but limited data suggest they may be associated with increased blunt bowel (small bowel or colon) injuries (BI). Unfortunately, this risk is unquantified. METHODS: We analyzed the National Trauma Data Bank (2017-2019) using ICD-10 codes to identify adult motor vehicle occupants with BI who underwent surgical repair. We used logistic regression modeling to compare the risk of undergoing surgical repair for BI after using a protective device. RESULTS: Of 2,848,592 injured patients, 475,546 (16.7%) were motor vehicle occupants. Only 1.2% (n = 5627/475,546) of patients underwent a bowel repair or resection. Using a seat belt only was associated with an adjusted OR of 2.09 (95% CI 1.91, 2.28) for undergoing a bowel repair/resection when adjusting for Injury Severity Score (ISS) and age. Airbag deployment without a seat belt had an adjusted OR of 1.46 (95% CI 1.31, 1.62), while both devices combined conferred an OR of 3.27 (95% CI 3.02, 3.54). However, using a seat belt was protective against death with an OR of 0.50 (95% CI 0.48, 0.53), adjusted for age, sex, Charlson Comorbidity Score, and ISS. CONCLUSION: Seat belts and airbags are essential public health safety interventions and protect against death in motor vehicle-associated injuries. However, patients involved in MVCs with airbag deployment or while wearing a seat belt are at an increased risk of bowel injury requiring surgery compared to unrestrained patients, despite these events being relatively uncommon.

Posthospitalization outcomes after extracorporeal membrane oxygenation (ECMO) for COVID-19.

BACKGROUND: Critical illness from COVID-19 is associated with prolonged hospitalization and high mortality rates. Extracorporeal membrane oxygenation is used for refractory severe acute respiratory distress syndrome in COVID-19 with outcomes comparable to other indications for extracorporeal membrane oxygenation. However, long-term functional outcomes have yet to be fully elucidated. METHODS: We performed a retrospective chart review of 24 consecutive patients who required extracorporeal membrane oxygenation due to COVID-19 associated severe acute respiratory distress syndrome and survived to hospital discharge. After hospitalization, we contacted patients and administered the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 tool to assess longer-term outcomes. We abstracted demographics, clinical course, outcomes, and disposition variables from the electronic medical record. Descriptive statistical analysis was used on the retrospective data collection. RESULTS: Inpatient data were analyzed for 24 patients, and 21 of 24 (88%) patients completed the Patient-Reported Outcomes Measurement Information System tool at an average of 8.8 months posthospitalization. At hospital discharge, 62.5% of patients had ongoing oxygen requirements (nasal cannula, trach collar, or mechanical ventilation); 70.8% were discharged to a location other than home. However, at the time of follow-up, only 9.5% of patients required supplemental oxygen, all tracheostomies had been removed, and all patients resided at home. Patients reported relatively high levels of global physical function, and though there was a high reported incidence of fatigue, overall pain scores were low. CONCLUSION: Long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from coronavirus disease 2019 are promising. Extracorporeal membrane oxygenation therapy may confer morbidity benefits in patients with coronavirus disease and remains a valuable modality with excellent functional outcomes and preserved quality of life for survivors.

Acute Cholecystitis: A Review.

Importance: Gallbladder disease affects approximately 20 million people in the US. Acute cholecystitis is diagnosed in approximately 200 000 people in the US each year. Observations: Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis. Approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically in the setting of severe critical illness. The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness. Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis. When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy (a nuclear medicine study that includes the intravenous injection of a radiotracer excreted in the bile) is the gold standard diagnostic test. Following diagnosis, early (performed within 1-3 days) vs late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications (11.8% for early vs 34.4% for late), a shorter length of hospital stay (5.4 days vs 10.0 days), and lower hospital costs. During pregnancy, early laparoscopic cholecystectomy, compared with delayed operative management, is associated with a lower risk of maternal-fetal complications (1.6% for early vs 18.4% for delayed) and is recommended during all trimesters. In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up (15.2%) compared with nonoperative management (29.3%). A percutaneous cholecystostomy tube, in which a drainage catheter is placed in the gallbladder lumen under image guidance, is an effective therapy for patients with an exceptionally high perioperative risk. However, percutaneous cholecystostomy tube placement in a randomized trial was associated with higher rates of postprocedural complications (65%) compared with laparoscopic cholecystectomy (12%). For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy. Conclusions and Relevance: Acute cholecystitis, typically due to gallstone obstruction of the cystic duct, affects approximately 200 000 people in the US annually. In most patient populations, laparoscopic cholecystectomy, performed within 3 days of diagnosis, is the first-line therapy for acute cholecystitis.

Comparative outcomes between COVID-19 and influenza patients placed on veno-venous extracorporeal membrane oxygenation for severe ARDS.

BACKGROUND: ECMO is an established supportive adjunct for patients with severe, refractory ARDS from viral pneumonia. However, the exact role and timing of ECMO for COVID-19 patients remains unclear. METHODS: We conducted a retrospective comparison of the first 32 patients with COVID-19-associated ARDS to the last 28 patients with influenza-associated ARDS placed on V-V ECMO. We compared patient factors between the two cohorts and used survival analysis to compare the hazard of mortality over sixty days post-cannulation. RESULTS: COVID-19 patients were older (mean 47.8 vs. 41.2 years, p = 0.033), had more ventilator days before cannulation (mean 4.5 vs. 1.5 days, p < 0.001). Crude in-hospital mortality was significantly higher in the COVID-19 cohort at 65.6% (n = 21/32) versus 36.3% (n = 11/28, p = 0.041). The adjusted hazard ratio over sixty days for COVID-19 patients was 2.81 (95% CI 1.07, 7.35) after adjusting for age, race, ECMO-associated organ failure, and Charlson Comorbidity Index. CONCLUSION: ECMO has a role in severe ARDS associated with COVID-19 but providers should carefully weigh patient factors when utilizing this scarce resource in favor of influenza pneumonia.

Time to Cannulation after ICU Admission Increases Mortality for Patients Requiring Veno-venous ECMO for COVID-19 Associated Acute Respiratory Distress Syndrome.

OBJECTIVE: COVID-19 can cause ARDS that is rapidly progressive, severe, and refractory to conventional therapies. ECMO can be used as a supportive therapy to improve outcomes but evidence-based guidelines have not been defined. SUMMARY BACKGROUND DATA: Initial mortality rates associated with ECMO for ARDS in COVID-19 were high, leading some to believe that there was no role for ECMO in this viral illness. With more experience, outcomes have improved. The ideal candidate, timing of cannulation, and best postcannulation management strategy, however, has not yet been defined. METHODS: We conducted a retrospective review from April 1 to July 31, 2020 of the first 25 patients with COVID-19 associated ARDS placed on V-V ECMO at our institution. We analyzed the differences between survivors to hospital discharge and those who died. Modified Poisson regression was used to model adjusted risk factors for mortality. RESULTS: Forty-four patients (11/25) survived to hospital discharge. Survivors were significantly younger (40.5 years vs 53.1 years; P < 0.001) with no differences between cohorts in mean body mass index, diabetes, or PaO2:-FiO2 at cannulation. Survivors had shorter duration from symptom onset to cannulation (12.5 days vs 19.9 days, P = 0.028) and shorter duration of intensive care unit (ICU) length of stay before cannulation (5.6 days vs 11.7 days, P = 0.045). Each day from ICU admission to cannulation increased the adjusted risk of death by 4% and each year increase in age increased the adjusted risk 6%. CONCLUSIONS: ECMO has a role in severe, refractory ARDS associated with COVID-19. Increasing age and time from ICU admission were risk factors for mortality and should be considered in patient selection. Further studies are needed to define best practices for V-V ECMO use in COVID-19.

Trends in head injury associated mortality in Malawi.

BACKGROUND: To address the problem of surgical workforce deficiencies in Malawi, we partnered with local institutions to establish a surgical residency-training and educational program for local surgeons in 2009. While this program has improved trauma-associated outcomes, it is unclear whether, without additional system improvements, the management of traumatic brain injury (TBI) has similarly advanced. This study sought to describe trends of TBI-associated in-hospital trauma mortality at a tertiary trauma center in sub-Saharan Africa. METHODS: We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi, from 2012 through 2017. Modified Poisson regression modeling was used to compare the risk ratio of TBI associated in-hospital death each year compared to the year 2012, after adjusting for relevant covariates. RESULTS: 87,295 patients were recorded into the KCH Trauma Registry. 3,393 patients with TBI were identified, and most TBI patients were young males. In 2013 (RR 0.66, 95% CI 0.48, 0.92) and 2014 (RR 0.57, 95% CI 0.41, 0.79), the adjusted risk ratio of in-hospital death decreased compared to 2012 when adjusted for age, sex, initial AVPU score, transfer status, and multisystem trauma. However, the adjusted risk ratio of mortality in 2015 (0.73, 95% CI 0.53, 1.02) plateaued, with relatively minor improvements in 2016 (0.72, 95% CI 0.54, 0.97) and 2017 (0.71, 95% CI 0.53, 0.96). CONCLUSIONS: A decrease in TBI associated mortality was associated with the establishment of a residency and educational training program for general surgery. This program increased available surgeons, improved critical care and trauma training, and integrated some neurosurgical training. However, improvements in outcomes plateaued in the last few years of the study, despite these enhancements to surgical care. The general surgery workforce must be supplemented with improved neurosurgical services and neurocritical care to decrease TBI-related mortality.

Predictors of multi-drug resistance in burn wound colonization following burn injury in a resource-limited setting.

INTRODUCTION: Bacterial resistance to antibiotics is growing dramatically worldwide due to several contributing factors, including inappropriate antibiotic utilization in the clinical setting and widespread use in the food production industry. Consequently, it is imperative to characterize antibiotic resistance in high-risk populations, such as burn patients, particularly in resource-limited settings where prevention strategies may be high-yield and new antibiotics are not readily available. We therefore sought to characterize and identify predictors of multi-drug resistant (MDR) bacteria colonization in burn patients at our center in Malawi. METHODS: This is a prospective analysis of burn patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi within 72 h of burn injury. A swab of each patient's primary wound was collected at admission and each subsequent week. The primary aim was to determine predictors of colonization in burn wounds with multi-drug resistant bacteria using modified Poisson regression modeling. RESULTS: 99 patients were enrolled and analyzed. The median age was 4 years (IQR 2-12) with a median % total burn surface area (TBSA) of 14% (IQR 9-25). The most common burn injury type was scald (n = 61, 61.6%), followed by flame (n = 37, 37.4%). Overall, 54 patients (54.6%) were colonized with MDR bacteria at some point during their hospitalization, with increases each week. For flame burns, the predictors of MDR bacterial colonization were each 1% increase of %TBSA (RR 1.01, 95% CI 1.00, 1.03, p = 0.038) and the use of operative intervention for burn treatment (RR 1.90, 95% CI 1.17, 3.09, p = 0.010). No variables were predictive of MDR wound colonization in scald burns. CONCLUSION: Our study identified that almost half of the patients in a Malawian burn unit had MDR bacteria colonizing burn wounds after only a week in the hospital. This increased to almost 70% during hospitalization. We also found that for patients with flame burns, increasing %TBSA, and operative intervention put patients at greater risk of MDR colonization. Interventions such as isolation of burn patients, consistent disinfection and sterilization of wards and operating rooms, and optimization of wound care management are imperative to decrease spread of MDR bacteria and to improve burn-associated clinical outcomes in resource-limited environments.

The effect of burn mechanism on pediatric mortality in Malawi: A propensity weighted analysis.

INTRODUCTION: The burden of global trauma disproportionately affects low- and middle-income countries, with a high incidence in children. Thermal injury represents one of the most severe forms of trauma and is associated with remarkable morbidity and mortality. The predictors of burn mortality have been well described (age, % total body surface area burn [TBSA], and presence of inhalation injury). However, the contribution of the burn mechanism as a predictor of burn mortality is not well delineated. METHODS: This is a retrospective analysis of prospectively collected data, utilizing the Kamuzu Central Hospital (KCH) Burn Surveillance Registry from May 2011 to August 2019. Pediatric patients (≤12 years) with flame and scald burns were included in the study. Basic demographic variables including sex, age, time to presentation, %TBSA, surgical intervention, burn mechanism, and in-hospital mortality outcome was collected. Bivariate analysis comparing demographic, burn characteristics, surgical intervention, and patient outcomes were performed. Standardized estimates were adjusted using inverse-probability of treatment weights (IPTW) to account for confounding. Following weighting, logistic regression modeling was performed to determine the odds of in-hospital mortality based on burn mechanism. RESULTS: During the study period, 2364 patients presented to KCH for burns and included in the database with 1794 (75.9%) pediatric patients. Of these, 488 (27.6%) and 1280 (72.4%) were injured by flame and scald burns, respectively. Males were 47.2% (n = 230) and 59.2% (n = 755) of the flame and scald burn cohorts, respectively (p < 0.001.) Patients presenting with flame burns compared to scald burns were older (4. 7 ± 3.1 vs. 2.7 ± 2.3 years, p < 0.001) with greater %TBSA burns (17.8 [IQR 10-28] vs 12 [IQR 7-20], p < 0.001). Surgery was performed for 42.2% (n = 206) and 19.9% (n = 140) of the flame and scald burn cohorts, respectively (p < 0.001.) Flame burns had a 2.6x greater odds of in-hospital mortality compared to scald burns (p < 0.001) after controlling for sex, %TBSA, age, time to presentation, and surgical status. CONCLUSION: In this propensity-weighted analysis, we show that burn mechanism, specifically flame burns, resulted in a nearly 3-fold increase in odds of in-hospital mortality compared to scald burns. Our results emphasize flame and scald burns have major differences in the inflammatory response, metabolic profile over time, and outcomes. We may further utilize these differences to develop specialized treatments for each burn mechanism to potentially prevent metabolic dysfunction and improve clinical outcomes.

Underutilization of Operative Capacity at the District Hospital Level in a Resource-Limited Setting.

INTRODUCTION: Improving surgical care in a resource-limited setting requires the optimization of operative capacity, especially at the district hospital level. METHODS: We conducted an analysis of the acute care surgery registry at Salima District Hospital in Malawi from June 2018 to November 2019. We examined patient characteristics, interventions, and outcomes. Modified Poisson regression modeling was used to identify risk factors for transfer to a tertiary center and mortality of patients transferred to the tertiary center. RESULTS: Eight hundred eighty-eight patients were analyzed. The most common diagnosis was skin and soft tissue infection (SSTI) at 35.9%. 27.5% of patients were transferred to Salima District Hospital, primarily from health centers, with a third for a diagnosis of SSTI. Debridement of SSTI comprised 59% of performed procedures (n = 241). Of the patients that required exploratory laparotomy, only 11 laparotomies were performed, with 59 patients transferred to a tertiary hospital. The need for laparotomy conferred an adjusted risk ratio (RR) of 10.1 (95% confidence interval [CI] 7.1, 14.3) for transfer to the central hospital. At the central hospital, for patients who needed urgent abdominal exploration, surgery had a 0.16 RR of mortality (95% CI 0.05, 0.50) while time to evaluation greater than 48 h at the central hospital had a 2.81 RR of death (95% CI 1.19, 6.66). CONCLUSIONS: Despite available capacity, laparotomy was rarely performed at this district hospital, and delays in care led to a higher mortality. Optimization of the district and health center surgical ecosystems is imperative to improve surgical access in Malawi and improve patient outcomes.

Access to Operative Intervention Reduces Mortality in Adult Burn Patients in a Resource-Limited Setting in Sub-Saharan Africa.

INTRODUCTION: Early excision and grafting remains the standard of care after burn injury. However, in a resource-limited setting, operative capacity often limits patient access to surgical intervention. This study sought to describe access to excision and grafting for adult burn patients in a sub-Saharan African burn unit and its relationship with burn-associated mortality. METHODS: We analyzed patients recorded in the Kamuzu Central Hospital Burn Registry in Lilongwe, Malawi from 2011-2019. We examined patient characteristics, interventions, and outcomes for adults aged ≥16 years. Modified Poisson regression modeling was used to identify risk factors for mortality. RESULTS: Five hundred and seventy-three patients were included. Median age was 30 years (IQR 23-40) with a male preponderance (63%). Median percent total body surface area burned (%TBSA) was 15% (IQR 8-26) and 68% of burns were caused by flame. 27% (n = 154) had burn excision with skin grafting, with a median time to operation of 18 days (IQR 9-38). When adjusted for age, %TBSA, and time to presentation, operative intervention conferred a survival benefit for patients with flame burns with a RR 0.16 (95% CI 0.06, 0.42). CONCLUSIONS: In a resource-limiting setting, access to the operating room is inadequate, and burn patients are not prioritized. While many scald burn patients may be managed with wound care alone, patients with flame burn require surgical intervention to improve clinical outcomes. Burn injury in this region continues to confer a high risk of mortality, and more investment in operative capacity is imperative.

The effect of traditional healer intervention prior to allopathic care on pediatric burn mortality in Malawi.

INTRODUCTION: Burn injury is a significant contributor to mortality, especially in low and middle-income countries (LMICs). Patients in many communities throughout sub-Saharan Africa use traditional health practitioners for burn care prior to seeking evaluation at an allopathic burn center. The World Health Organization defines a traditional health practitioner as "a person who is recognized by the community where he or she lives as someone competent to provide health care by using plant, animal and mineral substances and other methods based on social, cultural and religious practices based on indigenous knowledge and belief system." The aim of this study is to determine the prevalence of prior traditional health practitioner treatment and assess its effect on burn injury mortality. METHODS: A retrospective analysis of the prospectively collected Kamuzu Central Hospital (KCH) Burn Surveillance Registry was performed from January 2009 through July 2017. Pediatric patients (<13 years) who were injured with flame or scald burns were included in the study and we compared groups based on patient or family reported use of traditional health practitioners prior to evaluation at Kamuzu Central Hospital. We used propensity score weighted multivariate logistic regression to identify the association with mortality after visiting a traditional healer prior to hospitalization. RESULTS: 1689 patients were included in the study with a mean age of 3.3 years (SD 2.7) and 55.9% were male. Mean percent total body surface area of burn was 16.4% (SD 12.5%) and most burns were related to scald injuries (72.4%). 184 patients (10.9%) used traditional medicine prior to presentation. Only a delay in presentation was associated with prior traditional health practitioner use. After propensity weighted score matching, the odds ratio of mortality after using a prior traditional health practitioner was 1.91 (95% CI 1.09, 3.33). CONCLUSION: The use of traditional health practitioners prior to presentation at a tertiary burn center is associated with an increased odds of mortality after burn injury. These effects may be independent of the potential harms associated with a delay in definitive care. Further work is needed to delineate strategies for integrating with local customs and building improved networks for burn care, especially in rural areas.

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.

The role of endoscopy after upper gastrointestinal bleeding in sub-Saharan Africa: A prospective observational cohort study.

Background: Upper gastrointestinal (UGI) bleed is a common surgical disease in sub-Saharan Africa where there is often a lack of diagnostic and interventional adjuncts such as endoscopy. This study sought to characterize the role of endoscopy in management of acute UGI bleeding. Materials and Methods: This is a prospective observational analysis of adults presenting with an UGI bleed to a tertiary center in Lilongwe, Malawi, over two years. Patients were classified as having no endoscopy, diagnostic endoscopy, or endoscopy with variceal banding. Bivariate, survival analysis, and logistic regression analyses were used to compare intervention cohorts. Results: 293 patients were included with 49 patients (16.7%) receiving endoscopy with banding, 65 (22.2%) patients receiving diagnostic endoscopy only, and 179 (61.1%) receiving no endoscopy. Upon survival analysis comparing to the no endoscopy group, cox hazard modelling showed an adjusted hazard ratio over 30 days of 0.12 (95% CI 0.02, 0.88, p=0.038) for the endoscopic banding group and a hazard ratio of 0.39 (95% CI 0.13, 1.16, p=0.090) for the diagnostic endoscopy only group. Physical exam findings consistent with cirrhosis and decreasing age were independent predictors of an endoscopic diagnosis of variceal bleeding. Conclusion: Esophagogastric varices are a common cause of UGI bleeding in sub-Saharan Africa and can be predicted with age and physical exam findings. Endoscopy with variceal banding has a survival benefit for patients presenting with acute UGI bleed even with relatively low utilization. Appropriately triaging patients with likely variceal bleeding and improving endoscopy capacity would likely have a significant impact on mortality.

Diurnal variation in trauma mortality in sub-Saharan Africa: A proxy for health care system maturity.

BACKGROUND: Globally, traumatic injury is a leading cause of morbidity and mortality in low-income countries. However, trauma centers in these environments have limited resources to manage complex trauma with minimal staffing and diagnostic tools. These limitations may be exacerbated at night. We hypothesized that there is an increase in trauma-associated mortality for patients presenting during nighttime hours. METHODS: We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma registry in Lilongwe, Malawi from January 2012 through December 2016. Nighttime was defined as 18:00 until 5:59. Patients brought in dead were excluded. A modified Poisson regression model was used to calculate the relationship between presentation at night and mortality, adjusted for significant confounders. RESULTS: 74,500 patients were included. During the day, crude mortality was 0.8% compared to 1.4% at night (p < 0.001). The risk ratio of mortality following night time presentation compared to day was 1.90 (95% CI 1.48, 2.42) when adjusted for injury severity, assessed by the Malawi Trauma Score (MTS), and transfer status. When stratified by the year of traumatic injury, the risk ratio of death decreased each year from 2012-2014 but increased in 2015. There was no difference in 2016. CONCLUSIONS: We report the first description of diurnal variation in trauma-associated mortality in sub-Saharan Africa. Injured patients who presented at night had nearly twice the adjusted risk ratio of death compared to patients that presented during the daytime although there were yearly differences. Diurnal variation in trauma-associated mortality is a simple but important indicator of the maturity of a trauma system and should be tracked for health care system improvement.

Colonization with Multidrug-Resistant Enterobacteriaceae is Associated with Increased Mortality Following Burn Injury in Sub-Saharan Africa.

BACKGROUND: Multidrug-resistant (MDR) bacteria are an emerging international concern in low- and middle-income countries that threaten recent public health gains. These challenges are exacerbated in immunocompromised hosts, such as those with burn injury. This study sought to describe the epidemiology and associated clinical outcomes of burn wound colonization in a Malawian tertiary burn center. METHODS: This is a prospective analysis of burn patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, within 72 h of burn injury. A swab of each patient's primary wound was collected at admission and each subsequent week. The primary exposure was burn wound colonization with MDR bacteria, particularly Enterobacteriaceae. The primary outcome was in-hospital mortality. A log binomial model estimated the association between the exposure and outcome, adjusted for confounders. RESULTS: Ninety-nine patients were enrolled with a median age of 4 years (IQR 2-12) and a male preponderance (54%). Median total body surface area burn (TBSA) was 14% (IQR 9-25), and crude in-hospital mortality was 19%. Enterobacteriaceae were the most common MDR bacteria with 36% of patients becoming colonized. Wound colonization with MDR Enterobacteriaceae was associated with increased in-hospital mortality with a risk ratio of 1.86 (95% CI 1.38, 2.50, p < 0.001) adjusted for TBSA, burn type (scald vs. flame), sex, age, length of stay, and methicillin-resistant Staphylococcus aureus colonization. CONCLUSION: MDR bacteria, especially Enterobacteriaceae, are common and are associated with worse burn injury outcomes. In resource-poor environments, a greater emphasis on prevention of MDR bacterial colonization, improved isolation precautions, affordable diagnostics, and antibiotic stewardship are imperative.