Fractional excretion of sodium and potassium and urinary strong ion difference in the evaluation of persistent AKI in sepsis.

OBJECTIVE: To evaluate the diagnostic performance of FENa (Fractional excretion of sodium), FEK (fractional excretion of potassium) and uSID (urinary strong ion difference) in predicting pAKI in sepsis and septic shock. DESIGN: Retrospective cohort study. SETTING: Two intensive care units in Argentina. PATIENTS: Adult patients with a confirmed diagnosis of sepsis or septic shock and AKI, and had a urinary biochemistry within 24h of the AKI diagnosis. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: We evaluated the diagnostic accuracy of FENa, FEK and uSID through a ROC (Receiver Operating Characteristic) curve analysis. RESULTS: 80 patients were included. 40 patients presented pAKI. pAKI group had higher APACHE, SOFA score, and mortality rate. In the ROC curve analysis, uSID had no diagnostic utility (AUC=0.52, p=0.69). FENa presented moderate accuracy showing an AUC of 0.71 (95% CI 0.60-0.83; p=0.001), while FEK presented low accuracy with an AUC of 0.69 (95% CI 0.57-0.80; p=0.04). The optimal Youden point for identifying pAKI was at a FENa higher than 0.51 % with a specificity of 72.5% and a sensitivity of 65.0%. In the case of FEK, a value higher than 21.9 % presented the best relation, with a specificity of 67.5% and a sensitivity of 65.0%. CONCLUSIONS: urine biochemistry interpretation in septic patients must be revised. FENa and FEK are related to the severity of AKI and could be helpful complementary tools for diagnosing pAKI.

The Bidirectionality of Global Surgical Research: The Utility of the Malawi Trauma Score in the United States Trauma Population.

INTRODUCTION: Trauma scoring systems provide valuable risk stratification of injured patients. Trauma scoring systems developed in resource-limited settings, such as the Malawi Trauma Score (MTS), are based on readily available clinical information. This study sought to test the performance of the MTS in a United States trauma population. MATERIALS AND METHODS: We analyzed the United States National Trauma Data Bank during 2017-2020. MTS uses alertness score: alert, responds to verbal or painful stimuli, or unresponsive (AVPU), age, sex, presence of a radial pulse, and primary anatomic injury location. MTS and an age-adjusted version reflective of the US age distribution, was evaluated for its performance in predicting crude mortality in the National Trauma Data Bank using receiver operating characteristic analysis. We utilized logistic regression to model the odds ratio of death at a particular MTS cutoff. RESULTS: A total of 3,833,929 patients were included. The mean age was 49.3 y (sandard deviation 24.4), with a male preponderance (61.1%). Crude mortality was 3.4% (n = 131,452/3,833,929). The area under the curve for the MTS in predicting mortality was 0.87 (95% CI 0.87, 0.88). The area under the curve for a cutoff of 15 was 0.83 (95% CI 0.83, 0.83). An MTS of 15 higher had an odds ratio of death of 46.5 (95% CI 45.9, 47.1), compared to those with a score of 14 or lower. CONCLUSIONS: MTS has excellent performance as a predictor of mortality in a US trauma population. MTS is simple to calculate and can be estimated in the prehospital setting or the emergency department. Consequently, it may have utility as a triage tool in both high-income trauma systems and resource-limited settings.

Prognostic factors associated with advanced chronic kidney disease in a cohort of patients with ANCA vasculitis and renal involvement.

OBJECTIVE: The aim of this study was to evaluate prognostic factors associated with advanced chronic kidney disease (ACKD) in a cohort of patients with ANCA-associated vasculitis and renal involvement. METHODS: Observational retrospective study. We included patients with biopsy-proven ANCA glomerulonephritis (GN) diagnosed between 2001 and 2016, with at least 1-year follow-up. Data were recorded at diagnosis, end of induction, after 12 months of treatment, and at the end of follow-up. We analysed clinical-analytical data and renal histopathology, as well as treatments, dialysis requirement, relapses and death. Univariate analysis was performed to identify factors associated with long-term ACKD (eGFR < 30 ml/min). Multivariate analysis using an alternative outcome (eGFR at the end of follow-up) was performed. Diagnostic accuracy for ACKD of each predictor variable was compared using AUC of ROC curves. RESULTS: Sixty patients were included: 17 GPA, 14 MPA, 5 EGPA, and 24 RLV. Forty-six patients were women (76.7%). Mean age at diagnosis was 67.8 years (SD 13.1), and median follow-up time was 4.2 years (IQR 2.2-6.8). At the end of follow-up, 12 patients (20.0%) had an eGFR < 30 ml/min. Univariate analysis showed a statistically significant association of ACKD with sclerotic class biopsy (OR 7.17, 95% CI 1.34-38.31), 12-month proteinuria (OR 5.16, 95% CI 1.16-22.87), and creatinine at diagnosis (OR 1.24, 95% CI 1.02-1.52), end of induction (OR 15.40, 95% CI 2.41-98.28), and after 12 months (OR 19.25, 95% CI 2.75-134.92). In the multivariate analysis, eGFR at baseline (< 0.001), after 6 months (< 0.001) and 12 months of treatment (< 0.001), remained statistically associated with eGFR at the end of follow-up. The best diagnostic accuracy in ROC curves was shown by serum creatinine at the end of induction treatment (AUC 0.93) and after 12 months (AUC 0.94). CONCLUSION: In this cohort of patients with ANCA GN, creatinine and eGFR at baseline and after 6 and 12 months of treatment were the best predictors of ACKD at the end of follow-up.

[Clinical Practice Guidelines for diagnosis of organic involvement of amyloidosis: Part 3/3 Year 2020] / Guía de Práctica Clínica para el diagnóstico de compromiso orgánico en amiloidosis: Parte 3/3 Año 2020.

Method: Use the PICO format to generate a series of questions, focusing on the specificity and sensitivity of the amyloidosis diagnostic test. PubMed searches were conducted in English and Spanish from July to August 2019. The level of evidence and recommendation are based on the GRADE system (http://www.gradeworkinggroup.org/index.htm). The recommendations are graded according to their direction (for or against) and strength (strong and weak). Finally, it is recommended to use GLIA tools to evaluate the obstacles and facilitators in implementation. Suggested explanation A strong suggestion indicates a high degree of trust in support or opposition to the intervention. When defining a strong recommendation, this guide uses the "recommended" language. The weaker recommendations indicate that the outcome of the intervention (favorable or unfavorable) is doubtful. In this case, if a weak recommendation is defined, the "recommendation" language is used. How to use these guidelines: Recommendations must be explained within the scope of special care in validated diagnostic studies conducted by specially trained doctors. It is not assumed to change the coexistence conditions of the disease process. Presumably, the attending physician has a high degree of suspicion of amyloidosis. It assumes that diagnostic research is conducted by well-trained doctors using a validated standardized method. This guide is intended for health care professionals and those involved in health care policies to help ensure that the necessary agreements have been reached to provide appropriate care. Summary of recommendations For patients with suspected amyloidosis, it is recommended: Measured value of creatinine be used as a preliminary assessment for the diagnosis of renal involvement in patients with suspected renal amyloidosis. 24-hour proteinuria be measured and characterized to diagnose renal involvement in patients with suspected renal amyloidosis. Immunohistochemical staining of skin biopsy for patients genetically diagnosed with ATTR, for early diagnosis of neuropathy. The signs or symptoms of these patients suggest the presence of fine fiber neuropathy. Skin biopsy and immunohistochemical staining for early diagnosis of neuropathy. These patients show signs or symptoms suggesting fine fiber neuropathy. Conduct nerve conduction studies on motor and sensory fibers to diagnose total fiber neuropathy in patients who are diagnosed or suspected of having amyloidosis. Test (Sudoscan) is recommended for the early diagnosis of peripheral autonomic neuropathy (even in asymptomatic patients) in patients with suspected autonomic neuropathy due to amyloidosis. Ewing's standard to measure heart rate variability to diagnose autonomic hypofunction in patients with autonomic neuropathy suspected of having amyloidosis. Measure orthostatic hypotension to diagnose early autonomic hypotension for patients with amyloidosis or systemic amyloidosis suspected of autonomic neuropathy. It is suggested: QST test to diagnose neuropathy early for patients genetically diagnosed with ATTR, if they show signs or symptoms suggesting fine fiber neuropathy Measure alkaline phosphatase to initially assess liver involvement in patients with amyloidosis.

Métodos: Se generó un listado de preguntas con el formato PICO centradas en la especificidad y sensibilidad de las pruebas diagnósticas en amiloidosis. Se realizó la búsqueda en PubMed durante julio-agosto del 2019, en inglés y español. Los niveles de evidencia y los grados de recomendación se basan en el sistema GRADE (http://www.gradeworkinggroup.org/index.htm). Las recomendaciones se graduaron según su dirección (a favor o en contra) y según fuerza (fuertes y débiles). Las recomendaciones finales fueron evaluadas con la herramienta GLIA para barreras y facilitadores en la implementación de éstas. Interpretación de recomendaciones: Las recomendaciones fuertes indican alta confianza, ya sea a favor o en contra, de una intervención. En esta guía se utiliza el lenguaje "se recomienda" cuando se define una recomendación fuerte. Las recomendaciones débiles indican que los resultados para una intervención, favorable o desfavorable, son dudosos. En este caso, se utiliza el lenguaje "se sugiere", cuando se define una recomendación débil.Cómo utilizar estas pautas: Las recomendaciones deben ser interpretadas en el contexto de la atención especializada, con estudios diagnósticos validados y realizados por médicos entrenados. Se asume que el médico tratante tiene alto nivel de sospecha de amiloidosis. No asume condiciones coexistentes que modifican el curso de la enfermedad. Asume que los estudios diagnósticos son realizados por médicos entrenados con métodos validados y estandarizados. Esta guía es relevante para los profesionales de la salud y los involucrados en las políticas sanitarias, para ayudar a asegurar que existan los acuerdos necesarios para brindar la atención adecuada. Resumen de recomendaciones En pacientes con sospecha de amiloidosis se recomienda: Medición de la creatinina como evaluación inicial para el diagnóstico del compromiso renal en el paciente con sospecha de amiloidosis renal. Medición y caracterización de la proteinuria de 24 hs para el diagnóstico de compromiso renal en pacientes con sospecha de amiloidosis renal. Biopsia de piel con tinción inmunohistoquímica para el diagnóstico precoz de neuropatía en pacientes con diagnóstico genético de ATTR, que presenten signos o síntomas sugestivos de neuropatía de fibra fina. Biopsia de piel con tinción inmunohistoquímica para el diagnóstico precoz de neuropatía en pacientes con sospecha de amiloidosis, que presenten signos o síntomas sugestivos de neuropatía de fibra fina. Estudios de conducción nerviosa evaluando fibras motoras y sensitivas para el diagnóstico de neuropatía de fibras gruesas en pacientes con diagnóstico o sospecha de amiloidosis. Prueba de QST para el diagnóstico precoz de neuropatía en pacientes con diagnóstico genético de ATTR, que presenten signos o síntomas sugestivos de neuropatía de fibras finas. Test de cuantificación sudorípara (Sudoscan) para diagnóstico precoz de neuropatía autonómica periférica (incluso en asintomáticos) en pacientes con sospecha de neuropatía autonómica por amiloidosis. Medición de la variabilidad de la frecuencia cardiaca con criterios de Ewing para el diagnóstico de disautonomía en pacientes con sospecha de neuropatía autonómica por amiloidosis. Medición de hipotensión ortostática con técnica adecuadamente estandarizada para el diagnóstico precoz de compromiso autonómico en el paciente con sospecha de neuropatía autonómica por amiloidosis o diagnóstico de amiloidosis sistémica Se sugiere: Prueba de QST para el diagnóstico precoz de neuropatía en pacientes con amiloidosis o sospecha de amiloidosis, que presenten signos o síntomas sugestivos de neuropatía de fibras finas. Medición de fosfatasa alcalina para evaluación inicial del compromiso hepático en el paciente con amiloidosis.

Tracheostomy without mechanical ventilation in patients with traumatic brain injury at a tertiary referral hospital in Malawi: a cross sectional study.

Background: Tracheostomy alone, without mechanical ventilation, has been advocated to maintain a free airway in patients with traumatic brain injury in low-income settings with minimal critical care capacity. However, no reports exist on the outcomes of this strategy. We examine the results of this practice at a central hospital in Malawi. Methods: This is a retrospective review of medical records and prospectively gathered trauma surveillance data of patients admitted to Kamuzu Central Hospital, with traumatic brain injury from January 2010 to December 2015. In-hospital mortality rates were examined according to registered traumatic brain injury severity and airway management. Results: In our analysis, 1875 of 2051 registered traumatic brain injury patients were included; 83.3% were male, mean age 32.6 (SD 12.9) years. 14.2% (n=267) of the patients had invasive airway management (endotracheal tube or tracheostomy) with or without mechanical ventilation. Mortality in severe traumatic brain injury treated with tracheostomy without mechanical ventilation was 42% (10/24) compared to 21% (14/68) in patients treated without intubation or tracheostomy (p= 0.043). Tracheostomies had an overall complication rate of 11%. Conclusion: Tracheostomy without mechanical ventilation in severe traumatic brain injury did not improve survival outcomes in our setting. Tracheostomy for severe traumatic brain injury cannot be recommended when mechanical ventilation is not available unless there are sufficient specialized human resources for follow up in the ward. Efforts to improve critical care facilities and human resource capacity to allow proper use of mechanical ventilation in severe traumatic brain injury should be a high priority in low-income countries where the burden of trauma is high.

Childhood Drownings: An Opportunity for Injury Prevention in a Resource-Limited Setting.

INTRODUCTION: Drowning is a public health problem that is under-reported in Africa. We sought to evaluate the epidemiology and risk factors for drownings in Malawi. METHODS: We performed a retrospective review of all pediatric (≤15 years old) patients who presented following a drowning incident to Kamuzu Central Hospital in Lilongwe, Malawi, from 2009-19. Demographics and outcomes were compared between survivors and non-survivors. Logistic multivariate regression analysis was used to identify factors associated with increased odds of mortality. RESULTS: There were 156 pediatric drowning victims during the study period. The median age at presentation was 3 (IQR: 2-7 years). Survivors were younger [median age: 2 years (IQR: 2-5) vs. 5 years (IQR: 2-10), p = 0.004], with a higher proportion of drownings occurring at home (85.6% vs. 58.3%, p = 0.001) compared to non-survivors. Patients who had a drowning event at a public space had increased odds of mortality (OR 8.17, 95% CI 2.34-28.6). Patients who were transferred (OR 0.03, 95% CI 0.003-0.25) and had other injuries (OR 0.20, 95% CI 0.06-0.70) had decreased odds of mortality following drowning. CONCLUSION: Over half of pediatric drowning victims at a tertiary-care facility in Malawi survived. Drowning survivors were significantly younger, more likely to have drowned at home, and transported by private vehicles and minibus than non-survivors. There is a need for scalable, cost-effective drowning prevention strategies that focus on water safety education and training community members and police officers in basic life support and resuscitation.

Characteristics of acute kidney injury in adult patients with severe COVID-19 / Características de la injuria renal aguda en pacientes adultos con COVID-19 grave

Abstract We conducted a retrospective cohort study to report the clinical characteristics, incidence and out-comes of patients with severe COVID-19 with acute kidney injury (AKI). One-hundred and sixtytwo intensive care unit (ICU) admitted patients in a tertiary level hospital in the city of Buenos Aires with COVID-19 diagnosis were included. We hypothesized that COVID-19 related AKI would develop in the period of more severe hypoxemia as an early event and late AKI would be more probably related to intensive care unit complications. For this purpose, we divided subjects into two groups: those with early AKI and late AKI, before and after day 14 from symptom onset, respectively. A stepwise multivariate analysis was conducted to find possible AKI predictors. AKI incidence was 43.2% (n = 70) of the total patients admitted into ICU with severe COVID-19, 11.1% (n = 18) required renal replacement therapy. In-hospital mortality was higher (58.6%) for the AKI group. AKI occurred on a median time of 10 (IQR 5.5-17.5) days from symptom onset. A history of hypertension or heart failure, age and invasive mechanical ventilation (IMV) requirement were identified as risk factors. Late AKI (n = 25, 35.7%) was associated with sepsis and nephrotoxic exposure, whereas early AKI occurred closer to the timing of IMV initiation and was more likely to have an unknown origin. In conclusion, AKI is frequent among critically ill patients with severe COVID-19 and it is associated with higher in-hospital mortality.

Resumen Llevamos a cabo un estudio retrospectivo con el objetivo de describir las características clínicas, incidencia y desenlaces de los pacientes con injuria renal aguda (IRA) asociada a la COVID-19. Se incluyeron 162 pacientes con diagnóstico de COVID-19 admitidos en una unidad de cuidados intensivos en un hospital de tercer nivel en la Ciudad de Buenos Aires. Nuestra hipótesis consistió en que la IRA asociada a COVID-19 sería un evento temprano asociado a la gravedad de la hipoxemia y la IRA tardía se relacionaría con complicaciones propias de la UCI. Por ello se clasificó la IRA en temprana y tardía, según sucediera antes o después de los 14 días desde el inicio de síntomas. Se realizó un análisis multivariado mediante regresión logística escalonada para evaluar posibles factores de riesgo. La incidencia de IRA fue de 43.2% (n = 70), 11.1% (n = 18) requirieron terapia de reemplazo renal. La mortalidad intrahospitalaria fue mayor (58.6%) en el grupo con IRA. El diagnóstico de IRA se realizó en una mediana de 10 (IQR = 5.5-17.5) días desde el inicio de los síntomas. El antecedente de hipertensión e insuficiencia cardíaca, la edad y el requerimiento de ventilación mecánica invasiva (VMI) fueron identificados como factores de riesgo para IRA. La IRA tardía (n = 25, 35.7%) estuvo asociada a sepsis y expo sición a nefrotóxicos, mientras que la IRA temprana (n = 45, 64.2%) estuvo temporalmente asociada al inicio de la VMI y en muchos casos no se pudo filiar una etiología. En conclusión, la IRA es una complicación frecuente en pacientes con COVID-19 grave y está asociada a una alta mortalidad intrahospitalaria.

Characteristics of acute kidney injury in adult patients with severe COVID-19.

We conducted a retrospective cohort study to report the clinical characteristics, incidence and outcomes of patients with severe COVID-19 with acute kidney injury (AKI). One-hundred and sixtytwo intensive care unit (ICU) admitted patients in a tertiary level hospital in the city of Buenos Aires with COVID-19 diagnosis were included. We hypothesized that COVID-19 related AKI would develop in the period of more severe hypoxemia as an early event and late AKI would be more probably related to intensive care unit complications. For this purpose, we divided subjects into two groups: those with early AKI and late AKI, before and after day 14 from symptom onset, respectively. A stepwise multivariate analysis was conducted to find possible AKI predictors. AKI incidence was 43.2% (n = 70) of the total patients admitted into ICU with severe COVID-19, 11.1% (n = 18) required renal replacement therapy. In-hospital mortality was higher (58.6%) for the AKI group. AKI occurred on a median time of 10 (IQR 5.5-17.5) days from symptom onset. A history of hypertension or heart failure, age and invasive mechanical ventilation (IMV) requirement were identified as risk factors. Late AKI (n = 25, 35.7%) was associated with sepsis and nephrotoxic exposure, whereas early AKI occurred closer to the timing of IMV initiation and was more likely to have an unknown origin. In conclusion, AKI is frequent among critically ill patients with severe COVID-19 and it is associated with higher in-hospital mortality.

Llevamos a cabo un estudio retrospectivo con el objetivo de describir las características clínicas, incidencia y desenlaces de los pacientes con injuria renal aguda (IRA) asociada a la COVID-19. Se incluyeron 162 pacientes con diagnóstico de COVID-19 admitidos en una unidad de cuidados intensivos en un hospital de tercer nivel en la Ciudad de Buenos Aires. Nuestra hipótesis consistió en que la IRA asociada a COVID-19 sería un evento temprano asociado a la gravedad de la hipoxemia y la IRA tardía se relacionaría con complicaciones propias de la UCI. Por ello se clasificó la IRA en temprana y tardía, según sucediera antes o después de los 14 días desde el inicio de síntomas. Se realizó un análisis multivariado mediante regresión logística escalonada para evaluar posibles factores de riesgo. La incidencia de IRA fue de 43.2% (n = 70), 11.1% (n = 18) requirieron terapia de reemplazo renal. La mortalidad intrahospitalaria fue mayor (58.6%) en el grupo con IRA. El diagnóstico de IRA se realizó en una mediana de 10 (IQR = 5.5-17.5) días desde el inicio de los síntomas. El antecedente de hipertensión e insuficiencia cardíaca, la edad y el requerimiento de ventilación mecánica invasiva (VMI) fueron identificados como factores de riesgo para IRA. La IRA tardía (n = 25, 35.7%) estuvo asociada a sepsis y exposición a nefrotóxicos, mientras que la IRA temprana (n = 45, 64.2%) estuvo temporalmente asociada al inicio de la VMI y en muchos casos no se pudo filiar una etiología. En conclusión, la IRA es una complicación frecuente en pacientes con COVID-19 grave y está asociada a una alta mortalidad intrahospitalaria.

The unmet need for treatment of children with musculoskeletal impairment in Malawi.

BACKGROUND: More than a billion people globally are living with disability and the prevalence is likely to increase rapidly in the coming years in low- and middle-income countries (LMICs). The vast majority of those living with disability are children residing in LMICs. There is very little reliable data on the epidemiology of musculoskeletal impairments (MSIs) in children and even less is available for Malawi. Previous studies in Malawi on childhood disability and the impact of musculoskeletal impairment (MSI) on the lives of children have been done but on a small scale and have not used disability measurement tools designed for children. Therefore in this study, we aimed to estimate the MSI prevalence, causes, and the treatment need among children aged 16 years or less in Malawi. METHODS: This study was carried out as a national cross sectional survey. Clusters were selected across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the national distribution of the population. Clusters were distributed around all 27-mainland districts of Malawi. Population of Malawi was 18.3 million from 2018 estimates, based on age categories we estimated that about 8.9 million were 16 years and younger. MSI diagnosis from our randomized sample was extrapolated to the population of Malawi, confidence limits was calculated using normal approximation. RESULTS: Of 3792 children aged 16 or less who were enumerated, 3648 (96.2%) were examined and 236 were confirmed to have MSI, giving a prevalence of MSI of 6.5% (CI 5.7-7.3). Extrapolated to the Malawian population this means as many as 576,000 (95% CI 505,000-647,000) children could be living with MSI in Malawi. Overall, 46% of MSIs were due to congenital causes, 34% were neurological in origin, 8.4% were due to trauma, 7.8% were acquired non-traumatic non-infective causes, and 3.4% were due to infection. We estimated a total number of 112,000 (80,000-145,000) children in need of Prostheses and Orthoses (P&O), 42,000 (22,000-61,000) in need of mobility aids (including 37,000 wheel chairs), 73,000 (47,000-99,000) in need of medication, 59,000 (35,000-82,000) in need of physical therapy, and 20,000 (6000-33,000) children in need of orthopaedic surgery. Low parents' educational level was one factor associated with an increased risk of MSI. CONCLUSION: This survey has uncovered a large burden of MSI among children aged 16 and under in Malawi. The burden of musculoskeletal impairment in Malawi is mostly unattended, revealing a need to scale up both P&O services, physical & occupational therapy, and surgical services in the country.

Latin American registry of renal involvement in COVID-19 disease. The relevance of assessing proteinuria throughout the clinical course.

The Latin American Society of Nephrology and Hypertension conducted a prospective cohort, multinational registry of Latin American patients with kidney impairment associated to COVID-19 infection with the objective to describe the characteristics of acute kidney disease under these circumstances. The study was carried out through open invitation in order to describe the characteristics of the disease in the region. Eight-hundred and seventy patients from 12 countries were included. Median age was 63 years (54-74), most of patients were male (68.4%) and with diverse comorbidities (87.2%). Acute kidney injury (AKI) was hospital-acquired in 64.7% and non-oliguric in 59.9%. Multiorgan dysfunction syndrome (MODS) due to COVID-19 and volume depletion were the main factors contributing to AKI (59.2% and 35.7% respectively). Kidney replacement therapy was started in 46.2%. Non-recovery of renal function was observed in 65.3%. 71.5% of patients were admitted to ICU and 72.2% underwent mechanical ventilation. Proteinuria at admission was present in 62.4% of patients and proteinuria during hospital-stay occurred in 37.5%. Those patients with proteinuria at admission had higher burden of comorbidities, higher baseline sCr, and MODS was severe. On the other hand, patients with de novo proteinuria had lower incidence of comorbidities and near normal sCr at admission, but showed adverse course of disease. COVID-19 MODS was the main cause of AKI in both groups. All-cause mortality of the general population was 57.4%, and it was associated to age, sepsis as cause of AKI, severity of condition at admission, oliguria, mechanical ventilation, non-recovery of renal function, in-hospital complications and hospital stay. In conclusion, our study contributes to a better knowledge of this condition and highlights the relevance of the detection of proteinuria throughout the clinical course.

Paediatric surgical conditions in Malawi - A cross-sectional nationwide household survey.

Background: Untreated surgical conditions may lead to lifelong disability in children. Treating children with surgical conditions may reduce long-term effects of morbidity and disability. Unfortunately, low- and middle-income countries have limited resources for paediatric surgical care. Malawi, for example, has very few paediatric surgeons. There are also significantly inadequate infrastructures and personnel to treat these children. In order to strengthen resources that could provide such services, we need to begin by quantifying the need. Aim: To estimate the approximate prevalence of surgical conditions among children in Malawi, to describe the anatomical locations and diagnoses of the conditions and the presence of injuries. Methods: A cross-sectional, nationwide survey of surgical needs was performed in 28 of 29 districts of Malawi. Villages, households and household members were randomly selected. A total of 1487 households were visited and 2960 persons were interviewed. This paper is a sub analysis of the children in the dataset. Information was obtained from 255 living children and inquiry from household respondents for the 255 children who had died in the past year. The interviews were conducted by medical students over a 60-day period, and the validated SOSAS tool was used for data collection. Results: There were 67 out of 255 (26.3%) total children living with a surgical condition at the time of the study, with most of the conditions located in the extremities. Half of the children lived with problems due to injuries. Traffic accidents were the most common cause. Two-thirds of the children living with a surgical condition had some kind of disability, and one-third of them were grossly disabled. There were 255 total deceased children, with 34 who died from a surgical condition. The most prevalent causes of death were congenital anomalies of the abdomen, groin and genital region. Conclusion: An extrapolation of the 26% of children found to be living with a surgical condition indicates that there could be 2 million children living with a condition that needs surgical consultation or treatment in Malawi. Congenital anomalies cause significant numbers of deaths among Malawian children. Children living with surgical conditions had disorders in their extremities, causing severe disability. Many of these disorders could have been corrected by surgical care.

Prevalence, causes and impact of musculoskeletal impairment in Malawi: A national cluster randomized survey.

BACKGROUND: There is a lack of accurate information on the prevalence and causes of musculoskeletal impairment (MSI) in low income countries. The WHO prevalence estimate does not help plan services for specific national income levels or countries. The aim of this study was to find the prevalence, impact, causes and factors associated with musculoskeletal impairment in Malawi. We wished to undertake a national cluster randomized survey of musculoskeletal impairment in Malawi, one of the UN Least Developed Countries (LDC), that involved a reliable sampling methodology with a case definition and diagnostic criteria that could clearly be related to the classification system used in the WHO International Classification of Functioning, Disability and Health (ICF). METHODS: A sample size of 1,481 households was calculated using data from the latest national census and an expected prevalence based on similar surveys conducted in Rwanda and Cameroon. We randomly selected clusters across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the distribution of the population. In the field, randomization of households in a cluster was based on a ground bottle spin. All household members present were screened, and all MSI cases identified were examined in more detail by medical students under supervision, using a standardized interview and examination protocol. Data collection was carried out from 1st July to 30th August 2016. Extrapolation was done based on study size compared to the population of Malawi. MSI severity was classified using the parameters for the percentage of function outlined in the WHO International Classification of Functioning (ICF). A loss of function of 5-24% was mild, 25-49% was moderate and 50-90% was severe. The Malawian version of the EQ-5D-3L questionnaire was used, and EQ-5D index scores were calculated using population values from Zimbabwe, as a population value set for Malawi is not currently available. Chi-square test was used to test categorical variables. Odds ratio (OR) was calculated with a linear regression model adjusted for age, gender, location and education. RESULTS: A total of 8,801 individuals were enumerated in 1,481 households. Of the 8,548 participants that were screened and examined (response rate of 97.1%), 810 cases of MSI were diagnosed of which 18% (108) had mild, 54% (329) had moderate and 28% (167) had severe MSI as classified by ICF. There was an overall prevalence of MSI of 9.5% (CI 8.9-10.1). The prevalence of MSI increased with age, and was similar in men (9.3%) and women (9.6%). People without formal education were more likely to have MSI [13.3% (CI 11.8-14.8)] compared to those with formal education levels [8.9% (CI 8.1-9.7), p<0.001] for primary school and [5.9% (4.6-7.2), p<0.001] for secondary school. Overall, 33.2% of MSIs were due to congenital causes, 25.6% were neurological in origin, 19.2% due to acquired non-traumatic non-infective causes, 16.8% due to trauma and 5.2% due to infection. Extrapolation of these findings indicated that there are approximately one million cases of MSI in Malawi that need further treatment. MSI had a profound impact on quality of life. Analysis of disaggregated quality of life measures using EQ-5D showed clear correlation with the ICF class. A large proportion of patients with moderate and severe MSI were confined to bed, unable to wash or undress or unable to perform usual daily activities. CONCLUSION: This study has uncovered a high prevalence of MSI in Malawi and its profound impact on a large proportion of the population. These findings suggest that MSI places a considerable strain on social and financial structures in this low-income country. The Quality of Life of those with severe MSI is considerably affected. The huge burden of musculoskeletal impairment in Malawi is mostly unattended, revealing an urgent need to scale up surgical and rehabilitation services in the country.

Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue.

BACKGROUND: Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi. METHODS: We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality. RESULTS: We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation. CONCLUSIONS: Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.

Paediatric surgical conditions in Malawi ­ A cross-sectional nationwide household survey

Background:Untreated surgical conditions may lead to lifelong disability in children. Treating children with surgical conditions may reduce longterm effects of morbidity and disability. Unfortunately, low- and middle-income countries have limited resources for paediatric surgical care. Malawi, for example, has very few paediatric surgeons. There are also significantly inadequate infrastructures and personnel to treat these children. In order to strengthen resources that could provide such services, we need to begin by quantifying the need.Aim: To estimate the approximate prevalence of surgical conditions among children in Malawi, to describe the anatomical locations and diagnoses of the conditions and the presence of injuries. Methods A cross-sectional, nationwide survey of surgical needs was performed in 28 of 29 districts of Malawi. Villages, households and household members were randomly selected. A total of 1487 households were visited and 2960 persons were interviewed. This paper is a sub analysis of the children in the dataset. Information was obtained from 255 living children and inquiry from household respondents for the 255 children who had died in the past year. The interviews were conducted by medical students over a 60-day period, and the validated SOSAS tool was used for data collection. Results:There were 67 out of 255 (26.3%) total children living with a surgical condition at the time of the study, with most of the conditions located in the extremities. Half of the children lived with problems due to injuries. Traffic accidents were the most common cause. Two-thirds of the children living with a surgical condition had some kind of disability, and one-third of them were grossly disabled. There were 255 total deceased children, with 34 who died from a surgical condition. The most prevalent causes of death were congenital anomalies of the abdomen, groin and genital region. Conclusion: An extrapolation of the 26% of children found to be living with a surgical condition indicates that there could be 2 million children living with a condition that needs surgical consultation or treatment in Malawi. Congenital anomalies cause significant numbers of deaths among Malawian children. Children living with surgical conditions had disorders in their extremities, causing severe disability. Many of these disorders could have been corrected by surgical care.

Prevalence of alcohol use among road traffic crash victims presenting to a Malawian Central Hospital: A cross-sectional study.

BACKGROUND: Alcohol consumption is a well-known risk factor for sustaining road traffic injuries worldwide. Malawi is a low-income country with a large and increasing burden of road traffic injuries. It has generally been viewed as a country with relatively little alcohol consumption. This study investigates the role of alcohol in road traffic injuries in and around the capital Lilongwe. METHODS: All patients presenting to the emergency department of Kamuzu Central Hospital after being injured in road traffic crashes were asked to participate in the study. Alcohol testing was done with a breathalyzer or a saliva test. Participants were asked about alcohol use before the injury as well as hazardous drinking using the AUDIT-C questionnaire. RESULTS: Of 1347 patients age 18 years or older who were asked to participate, 1259 gave informed consent, and data on alcohol use (alcohol test results and/or self-reported intake) were available for 1251 participants. Of those, 251 (20.1%) tested positive for alcohol, whereas 221 (17.7%) reported alcohol use before the crash; in total 311 (24.9%, 95% CI 22.5-27.3) either tested positive, reported use, or both. Females had a low prevalence of alcohol use (2.5%), while 30.6% of males had consumed alcohol before the injuries. Pedestrians had the highest prevalence at 41.8% (95% CI 35.5-48.4), while car drivers had 23.8% (95% CI 18.2-30.5). Among male pedestrians, 49.5% had used alcohol before the injury. Alcohol-associated injuries had a peak in the evening and at night, especially in the weekends. Of the patients, 63.1% reported that they had not consumed alcohol during the last year, while 21.4% had an AUDIT-C score suggesting hazardous drinking, and 66.2% of those had used alcohol before the injury. CONCLUSIONS: A large percentage of road traffic injured patients had been drinking alcohol before their injury, especially male pedestrians. A large proportion of the patients were abstaining from alcohol, but those not abstaining had a high prevalence both of alcohol use when injured and hazardous drinking identified by AUDIT-C. This has important implications for prevention.

Deaths from surgical conditions in Malawi - a randomised cross-sectional Nationwide household survey.

BACKGROUND: Relatively little is known about deaths from surgical conditions in low- and middle- income African countries. The prevalence of untreated surgical conditions in Malawi has previously been estimated at 35%, with 24% of the total deaths associated with untreated surgical conditions. In this study, we wished to analyse the causes of deaths related to surgical disease in Malawi and where the deaths took place; at or outside a health facility. METHODS: The study is based on data collected in a randomised multi-stage cross-sectional national household survey, which was carried out using the Surgeons Overseas Assessment of Surgical Need (SOSAS) tool. Randomisation was done on 48,233 settlements, using 55 villages from each district as data collection sites. Two to four households were randomly selected from each village. Two members from each household were interviewed. A total of 1479 households (2909 interviewees) across the whole country were visited as part of the survey. RESULTS: The survey data showed that in 2016, the total number of reported deaths from all causes was 616 in the 1479 households visited. Data related to cause of death were available for 558 persons (52.7% male). Surgical conditions accounted for 26.9% of these deaths. The conditions mostly associated with the 150 surgical deaths were body masses, injuries, and acute abdominal distension (24.3, 21.5 and 18.0% respectively). 12 women died from child delivery complications. Significantly more deaths from surgical conditions or injuries (55.3%) occurred outside a health facility compared to 43.6% of deaths from other medical conditions, (p = 0.0047). 82.3% of people that died sought formal health care and 12.9% visited a traditional healer additionally prior to their death. 17.7% received no health care at all. Of 150 deaths from potentially treatable surgical conditions, only 21.3% received surgical care. CONCLUSION: In Malawi, a large proportion of deaths from possible surgical conditions occur outside a health facility. Conditions associated with surgical death were body masses, acute abdominal distention and injuries. These findings indicate an urgent need for scale up of surgical services at all health care levels in Malawi.

The Inter-Relationship Between Employment Status and Interpersonal Violence in Malawi: A Trauma Center Experience.

INTRODUCTION: As a proportion of the overall population, sub-Saharan Africa (SSA) has the highest youth demographic, composing 60% of Africa's unemployed. With the worsening economic crisis in low- and middle-income countries, unengaged youth are susceptible to gang violence and anti-government demonstrations, resulting in political instability. METHODS: We performed a retrospective review of the Kamuzu Central Hospital Trauma Registry from 2008-2018. All adult patients (>14 years) injured by interpersonal violence (IPV) were included. Age was categorized as 15-24 (youth), 25-45, and >45 years. A bivariate analysis (IPV versus unintentional injury), and Poisson multivariable analysis were performed to identify factors increasing the risk of IPV. RESULTS: During the study, 87,338 trauma patients presented; 30,532 (35.0%) were injured following IPV. Patients injured following IPV (28 years, IQR 23-34) were younger than those unintentionally injured (30 years, IQR 23-39, p < 0.001). More patients injured following IPV were unemployed (n = 7,178, 23.6% vs. n = 10,148, 17.9%, p < 0.001), injured at night (n = 19,346, 63.7% vs. n = 10,148, 17.9%, p < 0.001), and reported alcohol use (n = 4.973, 16.4% vs n = 2,461, 4.4%, p < 0.001). Being unemployed (RR 1.25, 95% CI 1.22-1.27), youth compared to age >45 years (RR 1.72, 1.66-1.79), and those injured at night (RR 2.18, 95% CI 2.14-2.23) had increased the risk of being victims of IPV. CONCLUSION: In Malawi, there is an interrelationship between unemployment and IPV, particularly in the youth population. Given impending demographic realities, government and non-government organizations should prioritize youth employment to help defer political instability in vulnerable nation-states.

Design and Implementation of a Hospital-based Trauma Surveillance Registry in a Resource-Poor Setting: A Cost Analysis Study.

INTRODUCTION: Trauma is a leading cause of morbidity and mortality globally, with a disproportionate burden affecting low- and middle-income countries (LMIC). Rapid urbanization and differences in transportation patterns result in unique injury patterns in LMIC. Trauma registries are essential to determine the impact of trauma and the nature of injuries in LMIC to enable hospitals and healthcare systems to optimize care and to allocate resources. METHODS: A retrospective database analysis of prospectively collected data in the Kamuzu Central Hospital (KCH) Trauma Registry from 2018 - 2019 was performed. Activity-based costing, a bottom-up cost analysis method to determine the cost per patient registered, was completed after systematically analyzing the standard operating procedures of the KCH trauma registry. RESULTS: During the study period, 12,616 patients were included in the KCH Trauma Registry. Startup costs for the trauma registry are estimated at $3,196.24. This sum includes $1815.84 for personnel cost, $200 for database initiation (REDCap database), $342.50 for initial data clerk training, and $787.90 for registry and office supplies. Recurrent costs occurring in 2018, included personnel, technology, supply, and facility costs. Five data clerks, one data clerk manager, and a registry manager are required for 24/7 data collection, data integrity, and database maintenance, with an estimated cost of $29,697.24 per year. Yearly recurrent data clerk training costs are $137.00. Internet and facility costs for a data clerk office and secure record storage are $1632.60 per year. Supplies for the completion of trauma intake forms (binders, paper, pens) are $1431.80 per year. The total annual cost of the trauma registry at a tertiary hospital in Malawi is $33,361.64, which costs $2.64 per patient registered in the registry in 2018. CONCLUSION: Trauma registries are necessary for the assessment of the local trauma burden and injury pattern, but require significant financial commitment and time. To fully capture the local burden of trauma in resource-limited settings, acquiring, validating, and analyzing accurate data is crucial. Anticipating the financial burden of a trauma surveillance registry ahead of time is imperative.