Nd:YAG laser therapy for rectal and vaginal venous malformations.

BACKGROUND: Limited therapeutic options exist for rectal and vaginal venous malformations (VM). We describe our center's experience using Nd:YAG laser for targeted ablation of abnormal veins to treat mucosally involved pelvic VM. METHODS: Records of patients undergoing non-contact Nd:YAG laser therapy of pelvic VM at a tertiary children's hospital were reviewed. Symptoms, operative findings and details, complications, and outcomes were evaluated. RESULTS: Nine patients (age 0-24) underwent Nd:YAG laser therapy of rectal and/or vaginal VM. Rectal bleeding was present in all patients and vaginal bleeding in all females (n = 5). 5/7 patients had extensive pelvic involvement on MRI. Typical settings were 30 (rectum) and 20-25 W (vagina), with 0.5-1.0 s pulse duration. Patients underwent the same-day discharge. Treatment intervals ranged from 14 to 180 (average = 56) weeks, with 6.1-year mean follow-up. Five patients experienced symptom relief with a single treatment. Serial treatments managed recurrent bleeding successfully in all patients, with complete resolution of vaginal lesions in 40% of cases. No complications occurred. CONCLUSIONS: Nd:YAG laser treatment of rectal and vaginal VM results in substantial improvement and symptom control, with low complication risk. Given the high morbidity of surgical resection, Nd:YAG laser treatment of pelvic VM should be considered as first line therapy.

Qualitative analysis of a psychological supportive counseling group for burn survivors and families in Malawi.

OBJECTIVE: While psychological care, including supportive group therapy, is a mainstay of burn treatment in the developed world, few reports of support groups for burn survivors and their caregivers in the developing world exist. This study records the findings of a support group in Malawi and provides a qualitative analysis of thematic content discussed by burn survivors and caregivers. MATERIALS AND METHODS: We established a support group for burn survivors and caregivers from February-May 2012 in the burn unit at Kamuzu Central Hospital in Lilongwe, Malawi. Sessions were held weekly for twelve weeks and led by a Malawian counselor. The group leader compiled transcripts of each session and these transcripts were qualitatively analyzed for thematic information. RESULTS: Thematic analysis demonstrated a variety of psychological issues discussed by both survivors and caregivers. Caregivers discussed themes of guilt and self-blame for their children's injuries, worries about emotional distance now created between caregiver and survivor, fears that hospital admission meant likely patient death and concerns about their child's future and burn associated stigma. Burn survivors discussed frustration with long hospitalization courses, hope created through interactions with hospital staff, the association between mental and physical health, rumination about their injuries and how this would affect their future, decreased self-value, increased focus on their own mortality and family interpersonal difficulties. CONCLUSIONS: The establishment of a support group in our burn unit provided a venue for burn survivors and their families to discuss subjective experiences, as well as the dissemination of various coping techniques. Burn survivors and their caregivers in Malawi would benefit from the establishment of similar groups in the future to help address the psychological sequelae of burns.

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

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

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.

Epidemiology of pediatric injury in Malawi: burden of disease and implications for prevention.

PURPOSE: Pediatric injuries pose a significant health burden in sub-Saharan Africa, though historic data are too scarce to appreciate the extent of the problem. The purpose of this study is to utilize a comprehensive database to describe the epidemiology of pediatric injuries at a tertiary hospital in Malawi. METHODS: Data were prospectively collected on patients presenting to the emergency department for treatment of injuries from 2008 to 2010 (n = 23,625). The subset of pediatric patients (n = 7233) underwent cross-sectional analysis to examine demographics, injury environment, timing and mechanisms. RESULTS: Pediatric patients, (0-16 years) comprised 30.6% of all trauma patients. Mean age was 7.2 years. Falls were the most common injury (43%), followed by burns (11.1%), pedestrian road traffic injuries (9.7%), foreign bodies (7.5%), and assaults (7.2%). Statistically significant differences in injury pattern were observed between gender, age groups and season. After logistic regression, predictors of fall included male gender, home setting, and rainy season, whereas predictors of burn included female gender, age 0-5 yrs, home setting, and cold season. Predictors of pedestrian injury included age 6-10 yrs, female, and roadside setting. Predictors of foreign body ingestion included age 0-5 yrs, female gender, home setting, and daytime, and predictors of assault include male gender, age 11-16 yrs, nighttime hours. All predictors were statistically significant (p < 0.05). CONCLUSIONS: This study revealed patterns of injury based upon age, gender, location, and season. Our results may prove useful to stakeholders in injury prevention for designing, evaluating, and implementing programs to improve public safety in children in Malawi and similar resource poor nations.