Non-communicable disease burden among inpatients at a rural district hospital in Malawi.

BACKGROUND: The burden of non-communicable diseases (NCDs) is high in Malawi. However, resources and training for NCD care remain scarce, especially in rural hospitals. Current care for NCDs in the developing world focuses on the WHO's traditional 4 × 4 set. However, we do not know the full burden of NCDs outside of that scope, like neurological disease, psychiatric illness, sickle cell disease, and trauma. The goal of this study was to understand the burden of NCDs among inpatients in a rural district hospital in Malawi. We broadened our definition of NCDs beyond the traditional 4 × 4 set of NCDs, and included neurological disease, psychiatric illness, sickle cell disease, and trauma. METHODS: We conducted a retrospective chart review of all inpatients who were admitted to the Neno District Hospital between January 2017 and October 2018. We broke patients down by age, date of admission, type, and number of NCD diagnoses, and HIV status, and constructed multivariate regression models for length of stay and in-hospital mortality. RESULTS: Of 2239 total visits, 27.5% were patients with NCDs. Patients with NCDs were older (37.6 vs 19.7 years, p < 0.001) and made up 40.2% of total hospital time. We also found two distinct populations of NCD patients. The first were patients 40 years and older with primary diagnoses of hypertension, heart failure, cancer, and stroke. The second were patients under 40 years old with primary diagnoses of mental health conditions, burns, epilepsy, and asthma. We also found significant trauma burden, accounting for 40% of all NCD visits. In multivariate analysis, carrying a medical NCD diagnosis was associated with longer length of stay (coefficient 5.2, p < 0.001) and a higher risk of in-hospital mortality (OR 1.9, p = 0.03). Burn patients also had significantly longer length of stay (coefficient 11.6, p < 0.001). CONCLUSIONS: There is a significant burden of NCDs in a rural hospital in Malawi, including those outside of the traditional 4 × 4 set. We also found high rates of NCDs in the younger population (under 40 years of age). Hospitals must be equipped with adequate resources and training to meet this burden of disease.

Prolonged Exposure Dermatosis: Reporting High Incidence of an Undiagnosed Facial Dermatosis on a Winter Wilderness Expedition.

OBJECTIVE: Previously unclassified inflammatory skin lesions referred to as sun bumps have been observed throughout the year on participants of wilderness trips; however, the underlying cause and diagnosis remain unclear. The purpose of this prospective observational study was to document the incidence, characteristics, and risk factors associated with these skin lesions as they occurred on a winter wilderness expedition. METHODS: For this study, the lesions were defined as pruritic or erythematous skin lesions occurring while in the wilderness. Seventy-four participants in a wilderness ski touring course in Wyoming fully completed a 44-question written survey concerning occurrence and risk factors for these lesions. Weather information and photographs were collected. RESULTS: Twenty-six percent of participants had similar lesions. The lesions were described as edematous pale papules and plaques with erosions and crusts on an erythematous background. The face was involved in 90% of affected persons. Lesions occurred after an average of 8.7 days in the wilderness and resolved 10.6 days later. Skin that was less prone to sunburn was associated with a decreased incidence (odds ratio 0.44). No association could be found between lesion incidence and history of polymorphous light eruption, sun exposure, ambient temperature, affected contacts, sex, or body mass index. CONCLUSIONS: Overall, the lesions were common among study participants but occurred only after prolonged exposure to wilderness conditions. It was not possible to classify the skin condition as an example of any known diagnosis. We propose the name "prolonged exposure dermatosis" for this condition until further studies better define its etiology, prevention, and treatment.

Perceived barriers in the use of ultrasound in developing countries.

BACKGROUND: Access to ultrasound has increased significantly in resource-limited settings, including the developing world; however, there remains a lack of sonography education and ultrasound-trained physician support in developing countries. To further investigate this potential knowledge gap, our primary objective was to assess perceived barriers to ultrasound use in resource-limited settings by surveying care providers who practice in low- and middle-income settings. METHODS: A 25-question online survey was made available to health care providers who work with an ultrasound machine in low- and middle-income countries (LMICs), including doctors, nurses, technicians, and clinical officers. This was a convenience sample obtained from list-serves of ultrasound and radiologic societies. The survey was analyzed, and descriptive results were obtained. RESULTS: One hundred and thirty-eight respondents representing 44 LMICs including countries from the continents of Africa, South America, and Asia completed the survey, with a response rate of 9.6 %. Ninety-one percent of the respondents were doctors, and 9 % were nurses or other providers. Applications for ultrasound were diverse, including obstetrics (75 %), DVT evaluation (51 %), abscess evaluation (54 %), cardiac evaluation (64 %), inferior vena cava (IVC) assessment (49 %), Focused Assessment Sonography for Trauma (FAST) exam (64 %), biliary tree assessment (54 %), and other applications. The respondents identified the following barriers to use of ultrasound: lack of training (60 %), lack of equipment (45 %), ultrasound machine malfunction (37 %), and lack of ultrasound maintenance capability (47 %). Seventy-four percent of the respondents wished to have further training in ultrasound, and 82 % were open to receiving distance learning or telesonography training. Subjects used communication tools including Skype, Dropbox, emailed photos, and picture archiving and communication system (PACS) as ways to communicate and receive feedback on ultrasound images. CONCLUSIONS: Health care providers in the developing world identify lack of training as a primary barrier to regular use of ultrasound in their practice. While equipment requirements including maintenance and cost of machines are also important factors, future research is warranted on best practices for training methods, including telesonography and distance learning to enhance ultrasound use in low-resource settings.

Delayed diagnosis of gastric outlet obstruction from bouveret syndrome in a young woman.

Bouveret syndrome is a rare presentation of gastric outlet obstruction caused by a gallstone in the proximal duodenum via a bilioenteric fistula. This is an infrequent although clinically significant cause of abdominal pain, almost exclusively in the elderly. The clinical presentation is similar to that of a small bowel obstruction with abdominal pain, nausea and vomiting. Surgery or endoscopy is often required for definitive diagnosis and therapy. We describe the case of a young woman with this condition who had a delayed diagnosis in part because of her age and the rarity of the condition.