Optimizing Radiotherapy for Keloids: A Meta-Analysis Systematic Review Comparing Recurrence Rates Between Different Radiation Modalities.

BACKGROUND: The high recurrence rate of keloids has lead to the use of multiple treatment adjuncts to improve cosmetic outcomes after surgery. To date, there has been no single, standardized modality agreed upon to produce the best results. The purpose of this study was to review the radiation-based treatments (brachytherapy, electron beam and X-ray) used for keloid management and compare their outcomes. METHODS: A literature review was performed from 1942 to October 2014 using the databases: PubMed database of the National Center of Biotechnology Information, MEDLINE, Biosis, Embase, Google scholar, and Cochrane database. Articles were reviewed for case numbers, patient demographics, keloid location, follow up, radiation modality, dose, keloid recurrence, and complications. RESULTS: A total of 72 studies met the inclusion criteria representing 9048 keloids. These studies were categorized by treatment: brachytherapy, electron, or X-ray. Meta-analysis demonstrated that radiotherapy after surgery had less recurrence when compared to radiotherapy alone (22% and 37%, respectively, P = 0.005). Comparison between modalities revealed that postoperative brachytherapy yielded the lowest recurrence rate (15%) compared with X-ray and electron beam (23% and 23%, respectively; P =0.04, P = 0.1). Subgroup analysis by location demonstrated chest keloids have the highest recurrence rate. The most commonly reported side effect of radiotherapy was changes in skin pigmentation. CONCLUSIONS: The results of this study reinforce postoperative radiotherapy as effective management for keloids. Specifically, brachytherapy was the most effective of the currently used radiation modalities.

High morbidity and mortality after lower extremity injuries in Malawi: A prospective cohort study of 905 patients.

INTRODUCTION: A lower extremity injury can be a devastating event in low-income countries due to limited access to surgical care. Its incidence, treatment patterns, and outcomes, however, have not been well-described. METHODS: We prospectively enrolled all patients admitted with lower extremity trauma to a tertiary hospital in Lilongwe, Malawi between October 2010 and September 2011. Patients with a lower extremity injury but primarily admitted for unrelated reasons were excluded. The outcomes were deaths, complications, and length of hospital stay. RESULTS: Of the 905 patients eligible for analysis, 696 (77%) were males. Most patients had femur fractures (46%), and most were treated non-operatively (70%). Overall mortality rate was 3.9%. For adult patients with femur fractures, mortality was higher in patients treated with traction (9.0%) than for those treated with surgery (1.3%). The total complication rate was 15%, with adjusted odds of developing a complication higher in patients with concurrent head injury (OR = 2.8; 95% CI: 1.3-6.0), and patients who had an operative treatment (OR = 2; 95% CI: 1.2-1.9). The median length of stay was 16 days (IQR: 6-27) and was greatest among patients with femur fractures. CONCLUSION: Lower extremity injuries resulted in substantial mortality and morbidity in this low-income country. Mortality was particularly high among patients with femur fractures who did not have surgery. Modern orthopedic trauma surgery is greatly needed in low-income countries.

"Life is at a standstill" Quality of life after lower extremity trauma in Malawi.

PURPOSE: Low- and middle-income countries face a disproportionate burden of death and disability from injuries, many of which are due to road traffic accidents or falls. Lower extremity injuries in particular have implications not only for physical disabilities affecting work and school performance, but also for quality of life (QOL) of the individual. This qualitative study explores the psychosocial impact and QOL changes due to lower extremity injuries among trauma patients in central Malawi. METHODS: We transcribed and translated interviews with 20 patients who received care for a trauma to the lower extremity at a tertiary hospital in Lilongwe. We used NVivo to organize and thematically analyze the data. RESULTS: Participants reported limitations in physical functioning, activities of daily living, social roles, and vocational and social activities. Limited mobility led to unplanned long-term disruptions in work, personal financial loss, and household economic hardship. As a result, psychological distress, fears and worries about recovery, and poor perceptions of health and QOL were common. Several contextual factors influenced patient outcomes including socioeconomic status, religious beliefs, social networks, local landscape, housing structures, and transportation accessibility. CONCLUSION: Lower extremity trauma led to physical suffering and ongoing social and economic costs among Malawians. Injuries affecting mobility have broad QOL and economic consequences for patients and affected family members. Interventions are needed to improve post-injury recovery and QOL. Better access to trauma surgery and social and welfare support services for people living with disabling conditions are needed to alleviate the consequences of injuries.

The burden of surgical diseases on critical care services at a tertiary hospital in sub-Saharan Africa.

In many developing countries, including those of sub-Saharan Africa, care of the critically ill is poorly developed. We sought to elucidate the characteristics and outcomes of critically ill patients in order to better define the burden of disease and identify strategies for improving care. We conducted a cross sectional observation study of patients admitted to the intensive care unit at Kamuzu Central Hospital in 2010. Demographics, patient characteristics, clinical specialty and outcome data was collected for the 234 patients admitted during the study period. Older age and admission from trauma, general surgery or medical services were associated with increased mortality. The lowest mortality was among obstetrical and gynaecology patients. Use of the ventilator and transfusions were not associated with increased mortality. Patients with head injuries had the highest mortality rate. Rationing of critical care resources, using admitting diagnosis or scoring tools, can maximize access to critical care services in resource-limited settings. Furthermore, improvements of critical care services will be central to future efforts to reduce surgical morbidity and mortality and improving outcomes in all critically ill patients.

Intermediate follow-up after endovascular aneurysm repair: can we forgo CT scanning in certain patients?

Current recommendations for follow-up after endovascular repair of abdominal aortic aneurysms (EVAR) include yearly computed tomographic (CT) scans after the first year. We hypothesize that this is unnecessary for patients who have aneurysm sacs that are stable or shrinking at 1 year and no evidence of endoleak. To explore this hypothesis, we reviewed the records of all patients undergoing EVAR at our institution who were implanted with grafts that are currently commercially available and had a minimum of 18 months' follow-up. Of 415 patients who underwent EVAR over an 8-year period, 93 met the entry criteria. At a mean follow-up of approximately 3 years, secondary interventions were required in 13%, 39%, and 25% of patients undergoing EVAR with Zenith, AneuRx, and Excluder devices, respectively, and secondary interventions after the first year were required in 3%, 22%, and 8% of such grafts, respectively. Seventy-one patients (76%) had aneurysm sacs that were stable or shrinking at 1 year and no endoleak. Only two of these patients subsequently required reintervention. Both patients had AneuRx grafts, and both problems could have easily been identified without CT scanning. Our data support the hypothesis that patients who meet these criteria at 1 year are unlikely to have problems that cannot be identified by ultrasound and/or clinical evaluation alone and, thus, that CT scans are not necessary after this point, especially in patients with Zenith or reengineered Excluder devices.