Trauma Surgeons Experience Compassion Fatigue - A Major Metropolitan Area Survey.

INTRODUCTION: Compassion Fatigue (CF), the physical, emotional, and psychological impact of helping others, is composed of three domains: Compassion Satisfaction (CS), Secondary Traumatic Stress (STS), and Burnout (BO). Trauma surgeons (TS) experience work-related stress resulting in high rates of CF which can manifest as physical and psychological disorders. We hypothesized that TS experience CF and there are potentially modifiable systemic factors to mitigate its symptoms. METHODS: All TS in a major metropolitan area were eligible. Personal and professional demographic information was obtained. Each participant completed six validated surveys: 1) Professional Quality of Life Scale (Pro-QOL), 2) Perceived Stress Scale (PSS), 3) Multidimensional Scale of Perceived Social Support (MSPSS), 4) Adverse Childhood Events (ACE) Questionnaire, 5) Brief Coping Inventory (BCI), and 6) Toronto Empathy Questionnaire (TEQ). CF subscale risk scores (low:<23, moderate:23-41, high:>41) were recorded. Linear regression analysis assessed the demographic and environmental factors association with BO, STS, and CS. Variables significant on univariate analysis were included in multivariate models to determine the independent influence on BO, STS, and CS. Significance was p ≤ 0.05. RESULTS: There were 57 TS (response rate:75.4% (n = 43); Caucasian: 65% (n = 28), male:67% (n = 29)). TS experienced CF (BO:26 (IQR: 21-32), STS:23 (IQR: 19-32), CS:39 (IQR: 34-45)). The PSS score was significantly associated with increased BO (Coef: 0.52, 95% CI: 0.28-0.77) and STS (Coef: 0.44. 95% CI: 0.15-0.73), and decreased CS (Coef: -0.51, 95% CI: -0.80- -0.23) (p < 0.01). Night shifts were associated with higher BO (Coef: 1.55, 95% CI: 0.07-3.03, p = 0.05), conversely day shifts were associated with higher STS (Coef: 1.94, 95% CI: 0.32-3.56, p = 0.03). Higher TEQ scores were associated with greater CS (Coef: 0.33, 95% CI: 0.12-0.55, p < 0.01). CONCLUSION: TS experience moderate BO and STS associated with modifiable system- and work-related stressors. Efforts to reduce CF should focus on addressing sources of workplace stress and promoting empathic care. LEVEL OF EVIDENCE: III, Prognostic and Epidemiological.

Utilization of a Co-enrolled Course Structure for Point-of-Care Ultrasound Training in the Undergraduate Medical Education Setting.

With continuing advancements in software, electronics, and miniaturization, ultrasound (US) is quickly becoming an everyday tool of numerous medical specialties. With the advent of new handheld and other small-scale units, physicians have a tool to obtain on demand imaging without exposing the patient to ionizing radiation in the pocket of their white coat. As such, the need for competency in US is increasing. Currently, US training primarily occurs in residency, with only a handful of institutions incorporating US into the undergraduate medical education (UME) curriculum. To date, no ideal method has been presented (Amini et al., Intern Emerg Med. 10(5):613-8, 2015; Wilson et al., J Ultrasound Med. 36(2):321-5, 2017). Presented herein is a method for the addition of US training into the undergraduate medical curriculum. Utilizing a co-enrolled course format, 6 medical students were given basic training in the history and physics of US, echocardiography (ECHO), right upper quadrant (RUQ) ultrasound, focused assessment with sonography for trauma (FAST), and extended (eFAST) exams, vascular access techniques, and MSK ultrasound over 17 sessions. Students theoretical knowledge was assessed during team-based learning (TBL) sessions in an individual and group readiness assurance test (IRAT/GRAT) format. Students' practical skill was assessed in an objective structured clinical examination (OSCE) format. Students demonstrated notable proficiency with the US unit and were able to conduct both US-guided peripheral and central vascular access techniques. Furthermore, students were able to identify 80% or more of the required structures for the RUQ, ECHO, and eFAST US exams.

Implementation of a Nurse-Driven Protocol for Catheter Removal to Decrease Catheter-Associated Urinary Tract Infection Rate in a Surgical Trauma ICU.

INTRODUCTION: Early removal of urinary catheters is an effective strategy for catheter-associated urinary tract infection (CAUTI) prevention. We hypothesized that a nurse-directed catheter removal protocol would result in decreased catheter utilization and CAUTI rates in a surgical trauma intensive care unit (STICU). METHODS: We performed a retrospective, cohort study following implementation of a multimodal CAUTI prevention bundle in the STICU of a large tertiary care center. Data from a 19-month historical control were compared to data from a 15-month intervention period. Pre- and postintervention indwelling catheter utilization and CAUTI rates were compared. RESULTS: Catheter utilization decreased significantly with implementation of the nurse-driven protocol from 0.78 in the preintervention period to 0.70 in the postintervention period (P < .05). As a result of the bundle, the CAUTI rate declined significantly, from 5.1 to 2.0 infections per 1000 catheter-days in the pre- vs postimplementation period (Incident Rate Ratio [IRR]: 0.38, 95% confidence interval: 0.21-0.65). CONCLUSIONS: Implementation of a nurse-driven protocol for early urinary catheter removal as part of a multimodal CAUTI intervention strategy can result in measurable decreases in both catheter utilization and CAUTI rates.

The efficacy of interactive, motion capture-based rehabilitation on functional outcomes in an inpatient stroke population: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of novel interactive, motion capture-rehabilitation software to usual care stroke rehabilitation on physical function. DESIGN: Randomized controlled clinical trial. SETTING: Two subacute hospital rehabilitation units in Australia. PARTICIPANTS: In all, 73 people less than six months after stroke with reduced mobility and clinician determined capacity to improve. INTERVENTIONS: Both groups received functional retraining and individualized programs for up to an hour, on weekdays for 8-40 sessions (dose matched). For the intervention group, this individualized program used motivating virtual reality rehabilitation and novel gesture controlled interactive motion capture software. For usual care, the individualized program was delivered in a group class on one unit and by rehabilitation assistant 1:1 on the other. MAIN MEASURES: Primary outcome was standing balance (functional reach). Secondary outcomes were lateral reach, step test, sitting balance, arm function, and walking. RESULTS: Participants (mean 22 days post-stroke) attended mean 14 sessions. Both groups improved (mean (95% confidence interval)) on primary outcome functional reach (usual care 3.3 (0.6 to 5.9), intervention 4.1 (-3.0 to 5.0) cm) with no difference between groups ( P = 0.69) on this or any secondary measures. No differences between the rehabilitation units were seen except in lateral reach (less affected side) ( P = 0.04). No adverse events were recorded during therapy. CONCLUSION: Interactive, motion capture rehabilitation for inpatients post stroke produced functional improvements that were similar to those achieved by usual care stroke rehabilitation, safely delivered by either a physical therapist or a rehabilitation assistant.

Thoracoscopic Versus Open Congenital Diaphragmatic Hernia Repair: Single Tertiary Center Review.

BACKGROUND: Congenital diaphragmatic hernia (CDH) can be repaired open or through thoracoscopy. Thoracoscopic CDH repair could improve cosmesis and avoid the complications of laparotomy, but may have higher recurrence rates. The purpose of this study was to examine the outcomes of thoracoscopic versus open CDH repair, with regard to recurrence, perioperative parameters, and postoperative complications. METHODS: We performed a retrospective review of open versus thoracoscopic CDH repairs over an 8.5-year period. The primary outcome was hernia recurrence. Secondary outcomes included intraoperative partial pressure of carbon dioxide (pCO2) levels, length of stay, and postoperative complications. All statistical analyses were performed using standard statistical methods. RESULTS: A total of 54 infants underwent CDH repair during the study period, of whom 25 underwent successful thoracoscopic repair. Two patients who had undergone open repair developed recurrent diaphragmatic hernias (recurrence rate 3.7%). Operative time and intraoperative pCO2 levels did not differ between groups. Length of stay was shorter in the thoracoscopic cohort. Four patients in the open cohort developed ventral hernias and five developed bowel obstructions during follow-up. No long-term complications were identified in the thoracoscopic cohort. The median follow-up was 27 months. CONCLUSIONS: In our experience, thoracoscopic CDH repair was performed safely and with similar outcomes compared to open repair. In addition to improved cosmesis, thoracoscopic repair may avoid some of the long-term complications of laparotomy. In our series, none of the thoracoscopic CDH repairs recurred. We conclude that thoracoscopic CDH repair is a safe and appropriate technique for select neonates.

The effect of seasonality on burn incidence, severity and outcome in Central Malawi.

INTRODUCTION: In much of the world, burns are more common in cold months. However, few studies have described the seasonality of burns in sub-Saharan Africa. This study examines the effect of seasonality on the incidence and outcome of burns in central Malawi. METHODS: A retrospective analysis was performed at Kamuzu Central Hospital and included all patients admitted from May 2011 to August 2014. Demographic data, burn mechanism, total body surface area (%TBSA), and mortality were analyzed. Seasons were categorized as Rainy (December-February), Lush (March-May), Cold (June-August) and Hot (September-November). A negative binomial regression was used to assess the effect of seasonality on burn incidence. This was performed using both the raw and deseasonalized data in order to evaluate for trends not attributable to random fluctuation. RESULTS: A total of 905 patients were included. Flame (38%) and Scald (59%) burns were the most common mechanism. More burns occurred during the cold season (41% vs 19-20% in the other seasons). Overall mortality was 19%. Only the cold season had a statistically significant increase in burn . The incidence rate ratios (IRR) for the hot, lush, and cold seasons were 0.94 (CI 0.6-1.32), 1.02 (CI 0.72-1.45) and 1.6 (CI 1.17-2.19), respectively, when compared to the rainy season. Burn severity and mortality did not differ between seasons. CONCLUSION: The results of this study demonstrate the year-round phenomenon of burns treated at our institution, and highlights the slight predominance of burns during the cold season. These data can be used to guide prevention strategies, with special attention to the implications of the increased burn incidence during the cold season. Though burn severity and mortality remain relatively unchanged between seasons, recognizing the seasonal variability in incidence of burns is critical for resource allocation in this low-income setting.

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.

Sleep problems predict cortisol reactivity to stress in urban adolescents.

This study examined the role of sleep problems and sleep duration on stress-related HPA axis reactivity among urban, low income adolescents. A total of 84 adolescents (M age 13.36 years; 50% male; 95% African American) and their parents provided information on adolescents' sleep problems and sleep quantity. Adolescents completed a standardized social stress test in the laboratory (the Trier Social Stress Test; TSST). Saliva samples collected before and after the TSST yielded measures of cortisol pre-test, 15 min post-test, and 55 min post-test, as well as overall cortisol secretion and its increase (AUCG and AUCI). More sleep problems and longer sleep duration predicted higher cortisol reactivity to the TSST, particularly among females. Self-reports of sleep were more consistently related to stress-related cortisol reactivity than parent reports. Sleep problems and longer sleep duration may place adolescents at risk for HPA axis hyper-reactivity to stress, contributing to academic, behavioral and health problems.

The effect of incentive spirometry on postoperative pulmonary function following laparotomy: a randomized clinical trial.

IMPORTANCE: Changes in pulmonary dynamics following laparotomy are well documented. Deep breathing exercises, with or without incentive spirometry, may help counteract postoperative decreased vital capacity; however, the evidence for the role of incentive spirometry in the prevention of postoperative atelectasis is inconclusive. Furthermore, data are scarce regarding the prevention of postoperative atelectasis in sub-Saharan Africa. OBJECTIVE: To determine the effect of the use of incentive spirometry on pulmonary function following exploratory laparotomy as measured by forced vital capacity (FVC). DESIGN, SETTING, AND PARTICIPANTS: This was a single-center, randomized clinical trial performed at Kamuzu Central Hospital, Lilongwe, Malawi. Study participants were adult patients who underwent exploratory laparotomy and were randomized into the intervention or control groups (standard of care) from February 1 to November 30, 2013. All patients received routine postoperative care, including instructions for deep breathing and early ambulation. We used bivariate analysis to compare outcomes between the intervention and control groups. INTERVENTION: Adult patients who underwent exploratory laparotomy participated in postoperative deep breathing exercises. Patients in the intervention group received incentive spirometers. MAIN OUTCOMES AND MEASURES: We assessed pulmonary function using a peak flow meter to measure FVC in both groups of patients. Secondary outcomes, such as hospital length of stay and mortality, were obtained from the medical records. RESULTS: A total of 150 patients were randomized (75 in each arm). The median age in the intervention and control groups was 35 years (interquartile range, 28-53 years) and 33 years (interquartile range, 23-46 years), respectively. Men predominated in both groups, and most patients underwent emergency procedures (78.7% in the intervention group and 84.0% in the control group). Mean initial FVC did not differ significantly between the intervention and control groups (0.92 and 0.90 L, respectively; P=.82 [95% CI, 0.52-2.29]). Although patients in the intervention group tended to have higher final FVC measurements, the change between the first and last measured FVC was not statistically significant (0.29 and 0.25 L, respectively; P=.68 [95% CI, 0.65-1.95]). Likewise, hospital length of stay did not differ significantly between groups. Overall postoperative mortality was 6.0%, with a higher mortality rate in the control group compared with the intervention group (10.7% and 1.3%, respectively; P=.02 [95% CI, 0.01-0.92]). CONCLUSIONS AND RELEVANCE: Education and provision of incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy. We would not recommend the addition of incentive spirometry to the current standard of care in this resource-constrained environment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01789177.

The effect of a new surgery residency program on case volume and case complexity in a sub-Saharan African hospital.

BACKGROUND: Improved access to surgical care could prevent a significant burden of disease and disability-adjusted life years, and workforce shortages are the biggest obstacle to surgical care. To address this shortage, a 5-year surgical residency program was established at Kamuzu Central Hospital (KCH) in July 2009. As the residency enters its fourth year, we hypothesized that the initiation of a general surgical residency program would result in an increase in the overall case volume and complexity at KCH. METHODS: We conducted a retrospective analysis of operated cases at KCH during the 3 years before and the third year after the implementation of the KCH surgical residency program, from July 2006 to July 2009 and the calendar year 2012, respectively. RESULTS: During the 3 years before the initiation of the surgical residency, an average of 2317 operations were performed per year, whereas in 2012, 2773 operations were performed, representing a 20% increase. Before residency, an average of 1191 major operations per year were performed, and in 2012, 1501 major operations were performed, representing a 26% increase. CONCLUSION: Our study demonstrates that operative case volume and complexity increase following the initiation of a surgical residency program in a sub-Saharan tertiary hospital. We believe that by building on established partnerships and emphasizing education, research, and clinical care, we can start to tackle the issues of surgical access and care.

Hospital mortality following trauma: an analysis of a hospital-based injury surveillance registry in sub-Saharan Africa.

IMPORTANCE: Injuries are a significant cause of death and disability, particularly in low- and middle-income countries. Health care systems in resource-poor countries lack personnel and are ill equipped to treat severely injured patients; therefore, many injury-related deaths occur after hospital admission. OBJECTIVES: This study evaluates the mortality for hospitalized trauma patients at a tertiary care hospital in Malawi. DESIGN: This study is a retrospective analysis of prospectively collected trauma surveillance data. We performed univariate and bivariate analyses to describe the population and logistic regression analysis to identify predictors of mortality. SETTING: Tertiary care hospital in sub-Saharan Africa. PARTICIPANT: Patients with traumatic injuries admitted to Kamuzu Central Hospital between January 2010 and December 2012. MAIN OUTCOME MEASURES: Predictors of in-hospital mortality. RESULTS: The study population consisted of 7559 patients, with an average age of 27 years (±18 years) and a male predominance of 76%. Road traffic injuries, falls, and assaults were the most common causes of injury. The overall mortality was 4.2%. After adjusting for age, sex, type and mechanism of injury, and shock index, head/spine injuries had the highest odds of mortality, with an odds ratio of 5.80 (2.71-12.40). CONCLUSION AND RELEVANCE: The burden of injuries in sub-Saharan Africa remains high. At this institution, road traffic injuries are the leading cause of injury and injury-related death. The most significant predictor of in-hospital mortality is the presence of head or spinal injury. These findings may be mitigated by a comprehensive injury-prevention effort targeting drivers and other road users and by increased attention and resources dedicated to the treatment of patients with head and/or spine injuries in the hospital setting.

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.

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.

Cancer Treatment in Malawi: A Disease of Palliation.

BACKGROUND: Worldwide, new cancer cases will nearly double in the next 20 years while disproportionately affecting low and middle income countries (LMICs). Cancer outcomes in LMICs also remain bleaker than other regions of the world. Despite this, little is known about cancer epidemiology and surgical treatment in LMICs. To address this we sought to describe the characteristics of cancer patients presenting to the Surgery Department at Kamuzu Central Hospital in Lilongwe, Malawi. METHODS: We conducted a retrospective review of adult (18 years or older) surgical oncology services at Kamuzu Central Hospital in Lilongwe, Malawi from 2007 - 2010. Data obtained from the operating theatre logs included patient demographics, indication for operative procedure, procedure performed, and operative procedures (curative, palliative, or staging). RESULTS: Of all the general surgery procedures performed during this time period (7,076 in total), 16% (406 cases) involved cancer therapy. The mean age of male and female patients in this study population was 52 years and 47 years, respectively. Breast cancer, colorectal cancer, gastric cancer, and melanoma were the most common cancers among women, whereas prostate, colorectal, pancreatic, and, gastric were the most common cancers in men. Although more than 50% of breast cancer operations were performed with curative intent, most procedures were palliative including prostate cancer (98%), colorectal cancer (69%), gastric cancer (71%), and pancreatic cancer (94%). Patients with colorectal, gastric, esophageal, pancreatic, and breast cancer presented at surprisingly young ages. CONCLUSION: The paucity of procedures with curative intent and young age at presentation reveals that many Malawians miss opportunities for cure and many potential years of life are lost. Though KCH now has pathology services, a cancer registry and a surgical training program, the focus of surgical care remains palliative. Further research should address other methods of increasing early cancer detection and treatment in such populations.

Survival after burn in a sub-Saharan burn unit: challenges and opportunities.

BACKGROUND: Burns are among the most devastating of all injuries and a major global public health crisis, particularly in sub-Saharan Africa. In developed countries, aggressive management of burns continues to lower overall mortality and increase lethal total body surface area (TBSA) at which 50% of patients die (LA50). However, lack of resources and inadequate infrastructure significantly impede such improvements in developing countries. METHODS: This study is a retrospective analysis of patients admitted to the burn center at Kamuzu Central Hospital in Lilongwe, Malawi between June 2011 and December 2012. We collected information including patient age, gender, date of admission, mechanism of injury, time to presentation to hospital, total body surface area (TBSA) burn, comorbidities, date and type of operative procedures, date of discharge, length of hospital stay, and survival. We then performed bivariate analysis and logistic regression to identify characteristics associated with increased mortality. RESULTS: A total of 454 patients were admitted during the study period with a median age of 4 years (range 0.5 months to 79 years). Of these patients, 53% were male. The overall mean TBSA was 18.5%, and average TBSA increased with age--17% for 0-18 year olds, 24% for 19-60 year olds, and 41% for patients over 60 years old. Scald and flame burns were the commonest mechanisms, 52% and 41% respectively, and flame burns were associated with higher mortality. Overall survival in this population was 82%; however survival reduced with increasing age categories (84% in patients 0-18 years old, 79% in patients 19-60 years old, and 36% in patients older than 60 years). TBSA remained the strongest predictor of mortality after adjusting for age and mechanism of burn. The LA50 for this population was 39% TBSA. DISCUSSION: Our data reiterate that burn in Malawi is largely a pediatric disease and that the high burn mortality and relatively low LA50 have modestly improved over the past two decades. The lack of financial resources, health care personnel, and necessary infrastructure will continue to pose a significant challenge in this developing nation. Efforts to increase burn education and prevention in addition to improvement of burn care delivery are imperative.