Predictors of mortality following electrical and lightning injuries in Malawi: A decade of experience.

INTRODUCTION: Electrical injuries can be devastating, and data is lacking in low-resource settings. We aimed to identify predictors of mortality following electrical and lightning injuries (ELI) in Malawi. METHODS: We performed a retrospective observational study of patients presenting with ELI and burn injuries at a tertiary hospital in Malawi from 2011 to 2020. Outcomes were compared and predictors of mortality were modeled. RESULTS: A total of 382 ELI and 6371 burn patients were included. The mean ages for ELI and burn groups were 24 ± 14 and 11 ± 14 years, respectively (p < 0.01). Most patients were injured at home (91% in the burn group versus 51% in the ELI group, p < 0.01). The crude mortality rate in the ELI group was 28%, compared to 12% in the burn group (p < 0.01). On multivariate logistic regression, predictors of mortality included ELI (odds ratio [OR] 13.3, 95% confidence interval [CI] 7.2-24.5) and total body surface area burned (OR 1.1, 95% CI 1.1-1.1). Predicted mortality for ELI has increased over time (p = 0.05). CONCLUSIONS: ELI confers more than 13 times higher odds of mortality than burn injuries in Malawi, with mortality risk increasing over time. More efforts are needed to prevent electrical hazards and implement timely interventions for patients with ELI.

The Timing of Operative Intervention for Pediatric Burn Patients in Malawi.

BACKGROUND: Defining the optimal timing of operative intervention for pediatric burn patients in a resource-limited environment is challenging. We sought to characterize the association between mortality and the timing of operative intervention at a burn center in Lilongwe, Malawi. METHODS: This is a retrospective analysis of burn patients (<18 years old) presenting to Kamuzu Central Hospital from 2011 to 2022. We compared patients who underwent excision and/or burn grafting based on the timing of the operation. We used logistic regression modeling to estimate the adjusted odds ratio of death based on the timing of surgery. RESULTS: We included 2502 patients with a median age of 3 years (IQR 1-5) and a male preponderance (56.8%). 411 patients (16.4%) had surgery with a median time to surgery of 18 days (IQR 8-34). The crude mortality rate among all patients was 17.0% and 9.1% among the operative cohort. The odds ratio of mortality for patients undergoing surgery within 3 days from presentation was 5.00 (95% CI 2.19, 11.44) after adjusting for age, sex, % total burn surface area (TBSA), and flame burn. The risk was highest for the youngest patients. CONCLUSIONS: Children who underwent burn excision and/or grafting in the first 3 days of hospitalization had a much higher risk of death than patients undergoing surgical intervention later. Delaying operative intervention till >72 h for pediatric patients, especially those under 5 years old, may confer a survival advantage. More investment is needed in early resuscitation and monitoring for this patient population.

Tri-modal Distribution of Trauma Deaths in a Resource-Limited Setting: Perception Versus Reality.

BACKGROUND: Advances in trauma care in high-income countries have significantly reduced late deaths following trauma, challenging the classical trimodal pattern of trauma-associated mortality. While studies from low and middle-income countries have demonstrated that the trimodal pattern is still occurring in many regions, there is a lack of data from sub-Saharan Africa evaluating the temporal epidemiology of trauma deaths. METHODS: We conducted a retrospective analysis of the trauma registry at Kamuzu Central Hospital in Lilongwe, Malawi, including all injured patients presenting to the emergency department (ED) from 2009 to 2021. Patients were compared based on timing of death relative to time of injury. We then used a modified Poisson regression model to identify adjusted predictors for early mortality compared to late mortality. RESULTS: Crude mortality of patients presenting to the ED in the study period was 2.4% (n = 4,096/165,324). Most patients experienced a pre-hospital death (n = 2,330, 56.9%), followed by death in the ED (n = 619, 15.1%). Early death (pre-hospital or ED) was associated with transportation by police (RR1.52, 95% CI 1.38, 1.68) or private vehicle (RR1.20, 95% CI 1.07, 1.31), vehicle-related trauma (RR1.10, 95% CI 1.05, 1.14), and penetrating injury (RR1.11, 95% CI 1.04, 1.19). Ambulance transportation was associated with a 40% decrease in the risk of early death. CONCLUSIONS: At a busy tertiary trauma center in Malawi, most trauma-associated deaths occur within 48 h of injury, with most in the pre-hospital setting. To improve clinical outcomes for trauma patients in this environment, substantial investment in pre-hospital care is required through first-responder training and EMS infrastructure.

Sex-Based Differences in Survival Among Patients with Acute Abdomen Undergoing Surgery in Malawi: A Propensity Weighted Analysis.

INTRODUCTION: Sex disparities in access to health care in low-resource settings have been demonstrated. Still, there has been little research on the effect of sex on postoperative outcomes. We evaluated the relationship between sex and mortality after emergency abdominal surgery. METHODS: We performed a retrospective cohort study using the acute care surgery database at Kamuzu Central Hospital (KCH) in Malawi. We included patients who underwent emergency abdominal surgery between 2013 and 2021. We created a propensity score weighted Cox proportional hazards model to assess the relationship between sex and inpatient survival. RESULTS: We included 2052 patients in the study, and 76% were males. The most common admission diagnosis in both groups was bowel obstruction. Females had a higher admission shock index than males (0.91 vs. 0.81, p < 0.001) and a longer delay from admission until surgery (1.47 vs. 0.79 days, p < 0.001). Females and males had similar crude postoperative mortality (16.3% vs. 15.3%, p = 0.621). The final Cox proportional hazards regression model was based on the propensity-weighted cohort. The mortality hazard ratio was 0.65 among females compared to males (95% CI 0.46-0.92, p = 0.014). CONCLUSIONS: Our results show a survival advantage among female patients undergoing emergency abdominal surgery despite sex-based disparities in access to surgical care that favors males. Further research is needed to understand the mechanisms underlying these findings.

Predictors of mortality for perforated peptic ulcer disease in Malawi.

BACKGROUND: Mortality from perforated peptic ulcer disease (PUD) remains high, especially in sub-Saharan Africa. We sought to identify predictors of mortality following surgery for perforated PUD. METHODS: We performed a retrospective study of acute care surgeries at Kamuzu Central Hospital (KCH) in Malawi from 2013 to 2022. Patients undergoing omental patch surgeries were included. Bivariate and multivariate analyses were used to model predictors of mortality. RESULTS: A total of 248 patients were included. The mean age was 30 ± 15 years. Ninety percent were male. Mortality rate was 22.2%. Predictors of mortality included age (adjusted odds ratio [AOR] 1.06, 95% confidence interval [CI] 1.03-1.09), shock index (AOR 1.86, 95% CI 1.14-3.03), days to operative intervention (AOR 1.44, 95% CI 1.10-1.88), and presence of complications (AOR 9.65, 95% CI 3.79-24.6). CONCLUSIONS: Mortality following surgery for perforated PUD remains high in this low-resource environment. In-hospital delay is a significant and modifiable predictor of mortality.

Acute care surgery in a Malawian district hospital: Epidemiology, outcomes, and assessment of operative capacity.

District hospitals (DHs) care for the majority of surgical patients in Malawi, but data on district hospital surgical capacity are limited. We sought to evaluate the management and outcomes of surgical patients presenting to Salima District Hospital (SDH) in Malawi. Using the SDH surgery registry, we compared patients managed operatively and those non-operatively and performed logistic regression to identify factors associated with operative management. We then compared cases performed at SDH with procedures recommended to be performed at DHs. We included 1374 patients, of whom half were managed operatively. The most common procedures performed were abscess drainage and wound debridement. Logistic regression analysis revealed that patients with abdominal diagnoses were least likely to be treated operatively. Though SDH performs most procedures recommended for the district hospital level, patients requiring laparotomies were most likely to be transferred to a referral hospital. Future studies should assess barriers to performing laparotomies at SDH.

The effect of COVID-19 on burn management and outcomes in a resource-limited setting.

INTRODUCTION: Optimal burn care includes fluid resuscitation and early excision and grafting. During the COVID-19 pandemic, resource-constrained environments were susceptible to interruptions in burn care. We sought to characterize pre- and intra-pandemic burn-associated outcomes at a busy tertiary hospital in Malawi. METHODS: This is a retrospective analysis of burn patients that presented to Kamuzu Central Hospital Lilongwe from 2011 through December 2021. We compared patients based on whether they presented pre- or intra-pandemic, starting on March 11, 2020, the date of official WHO designation. Comparing these cohorts, we used modified Poisson modeling to estimate the adjusted risk of undergoing an operation and the risk of death. RESULTS: We included 2969 patients, with 390 presenting during the pandemic. Patient factors were similar between the cohorts. More patients underwent surgery pre-pandemic (21.1 vs 10.3 %, p < 0.001) but crude mortality was similar at 17.3 % vs. 21.2 % (p = 0.08). The RR of undergoing surgery during the pandemic was 0.45 (95 % CI 0.32, 0.64) adjusted for age, sex, % TBSA, flame burns, and time to presentation. During the pandemic, the risk ratio for in-hospital mortality was 1.23 (95 % CI 1.01, 1.50) adjusted for age, sex, % TBSA, surgical intervention, flame burns, and time to presentation. CONCLUSIONS: During the pandemic, the probability of undergoing burn excision or grafting was significantly lower for patients, independent of the severity. Consequently, the adjusted risk of mortality was higher. To improve patient outcomes, efforts to preserve operative capacity for burn patients during periods of severe resource constraint are imperative.

Direct Transfer to a Tertiary Care Hospital After Traumatic Injury is Associated with a Survival Benefit in a Resource-Limited Setting.

INTRODUCTION: Trauma is a leading cause of morbidity and mortality worldwide, and patients in low- and middle-income countries are disproportionately affected. Organized trauma systems, including appropriate transfer to a higher level of care, improve trauma outcomes. We sought to evaluate the relationship between transfer status and trauma mortality in Malawi. METHODS: We performed a retrospective analysis of trauma patients admitted to Kamuzu Central Hospital (KCH), a trauma center in Lilongwe, Malawi, between January 1, 2013, and May 30, 2018. Transfer status was categorized as direct if a patient arrives at KCH from the injury scene and indirect if a patient comes to KCH from another health care facility. We used logistic regression modeling to evaluate the relationship between transfer status and in-hospital mortality. RESULTS: A total of 8369 patients were included in the study. The mean age was 34.6 years (SD 15.8), and 81% of patients were male. The most common mechanism of injury was motor vehicle collision. Injury severity did not significantly differ between the two groups. Crude mortality was 4.8% for indirect and 2.6% for direct transfers. After adjusting for relevant covariates, odds ratio of mortality was 2.12 (1.49-3.02, p < 0.001) for indirect versus direct transfers. CONCLUSION: Trauma patients indirectly transferred to a trauma center have nearly double the risk of mortality compared to direct transfers. Trauma outcome improvement efforts must focus on strengthening prehospital care, improving district hospital capacity, and developing protocols for early assessment, treatment, and transfer of trauma patients to a trauma center.

Are Surgeons Enough? The Relationship between Increasing Surgical Demand and Access to Surgery in a Resource-Limited Environment.

INTRODUCTION: The relationship between increasing surgical demand and access to operative intervention remains unclear in delivering general surgical care in resource-limited settings, where demand often exceeds capacity. We sought to characterize the association between general surgery patient volume and operative intervention at a tertiary hospital in Malawi, which has an adequate surgical workforce. METHODS: We analyzed patients admitted to Kamuzu Central Hospital Lilongwe, Malawi, with a general surgery complaint from 2018-2020. We examined the relationship between the census at the time of admission, the use of operative intervention, and the time to operative intervention. The patient census was defined as low (≤30 patients), medium (31-49 patients), and high (≥50 patients), based on historical patterns. RESULTS: 2,701 patients were included. The mean daily census was 46 patients (SD 10). For the medium and high census, the adjusted risk ratio of undergoing surgery was 0.86 (95% CI 0.78, 0.95) and 0.81 (95% CI 0.73, 0.90), respectively, adjusted for admission diagnosis. For patients requiring urgent abdominal exploration, at a census of 25, the adjusted mean time to operation was 0.8 days (95% CI 0.1, 1.5) compared to 2.8 days (95% CI 2.1, 3.5) at a census of 65 patients. CONCLUSIONS: Despite an adequate surgical workforce, an increasing mean daily census significantly reduced the use of operative intervention and increased time to operation for patients who needed urgent abdominal exploration. Additional improvements in the surgical ecosystem beyond surgeons are necessary to improve surgical access.

Elderly trauma mortality in a resource-limited setting: A benchmark for process improvement.

INTRODUCTION: As life expectancy improves globally, the burden of elderly trauma continues to increase. Sub-Saharan Africa is projected to have the most rapid growth in its elderly demographic. Consequently, we sought to examine the trends in characteristics and outcomes of elderly trauma in a tertiary care hospital in Malawi. METHODS: We performed a retrospective analysis of adult patients in the trauma registry at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi from 2011-2017. Patients were categorized into elderly (≥ 65 years) and non-elderly (18-64 years). Bivariate analysis compared the characteristics and outcomes of elderly vs. non-elderly patients. The elderly population was then examined over the study period. Poisson regression modeling was used to determine the risk of mortality among elderly patients over time. RESULTS: Of 63,699 adult trauma patients, 1,925 (3.0%) were aged ≥ 65 years. Among the elderly, the most common mechanism of injury was falls (n = 725 [37.7%]) whereas vehicle or bike collisions were more common in the non-elderly (n = 15,967 [25.9%]). Fractures and dislocations were more prevalent in the elderly (n = 808 [42.0%] vs. 9,133 [14.8%], p < 0.001). In-hospital crude mortality for the elderly was double the non-elderly group (4.8% vs. 2.4%, p < 0.001). Elderly transfers, surgeries, and length of stay significantly increased over the study period but mortality remained relatively unchanged. When adjusted for injury severity and transfer status, there was no significant difference in risk of in-hospital mortality over time. CONCLUSION: At KCH, the proportion of elderly trauma patients is slowly increasing. Although healthcare resource utilization has increased over time, the overall trend in mortality has not improved. As the quality of care for the most vulnerable populations is a benchmark for the success of a trauma program, further work is needed to improve the trend in outcomes of the elderly trauma population in Malawi.

Self-inflicted injuries: The intersection of mental health and traumatic injury in Malawi.

Self-inflicted injury, the most common form of intentional injury, disproportionately affects low-income countries, but is poorly described in this setting. This retrospective review of the 2008-2018 trauma registry at a referral hospital in Malawi included all victims of intentional injury ≥10 years. Self-inflicted injuries were compared to assaults. The primary outcome was in-hospital mortality. Common mechanisms of self-inflicted injuries were fall from height, poisoning, and penetrating injury. In-hospital mortality from self-inflicted injury was 8.8% vs. 1.9% for assault. Those who died from self-inflicted injury were more often older (median 34 vs. 26 years, p < 0.001), male (91.9% vs. 67.8%, p < 0.001), unemployed (32.8% vs. 6.4%, p < 0.001), and most commonly died by hanging (60%). The odds of in-hospital mortality after self-inflicted injury was four times assault (OR 4.0 [95% CI 1.4-11.5], p = 0.01). The trauma registry proved useful for describing self-inflicted injury in this setting.

Characteristic and outcomes of human and animal bites in Malawi.

INTRODUCTION: Bites are an important contributor to traumatic injury worldwide. In low- and middle-income countries, data regarding bite injuries outside of rabies is limited. Therefore, we sought to describe the injury characteristics and outcomes of bites in Lilongwe, Malawi, and determine risk factors for animals and human bites. METHODS: We performed a retrospective analysis of the Kamuzu Central Hospital trauma registry from 2008-2018. We performed Bivariate analyses comparing bite to non-bite trauma and human to animal bites. Multivariable Poisson regression modeling then estimated risk factors for bites. RESULTS: A total of 124,394 patients were captured by the registry, of which 3,680 (3%) had a bite injury mechanism. Human bites accounted for 14.5% of bite injuries, and animals represented the remaining 85.5%. In rare cases, animal bite victims had serious complications, such as amputation (n = 6, 0.2%), orthopedic procedures (n = 5, 0.2%), and death (n = 7, 0.2%). Risk factors for an animal bite included being on a farm, field, or lake and being at home, whereas risk factors for a human bite included alcohol use and being at home. CONCLUSION: Animal bite injuries in Malawi can confer a risk of serious complications, such as amputation and, in rare cases, death. Alcohol-associated, in-home interpersonal violence is a significant risk factor for human bite injuries. Further studies are needed to identify risk factors for complications and mortality.

Trends and outcomes following intentional injuries in pediatric patients in a resource-limited setting.

INTRODUCTION: Intentional injuries pose a significant, yet underreported threat to children in sub-Saharan Africa. We sought to evaluate intentional injuries trends and compare outcomes between unintentional and intentional injuries in pediatric patients presenting to a tertiary care facility in Malawi. METHODS: We performed a review of pediatric (≤15 years old) trauma patients presenting to Kamuzu Central Hospital, Lilongwe, Malawi, from 2009 to 2018. Patient characteristics and outcomes were compared based on the injury intent, using bivariate and multivariate regression analysis. RESULTS: We included 42,600 pediatric trauma patients in the study. Intentional injuries accounted for 5.9% of all injuries. Children with intentional injuries were older (median, 10 vs. 6 years, p < 0.001), more likely to be male (68.4% vs. 63.9%, p < 0.001), and had significantly lower mortality (0.8% vs. 1.4%, p = 0.02) than those with unintentional injuries There was no significant change in the incidence of or mortality associated with intentional injuries. On multivariable regression, increasing age, head and cervical spine injury, night-time presentation, penetrating injury, and alcohol use were associated with increased risk of intentional harm. CONCLUSION: Intentional injury remains a significant cause of pediatric trauma in Malawi without decreasing hospital presentation incidence or mortality. In sub-Saharan Africa, there is a need to develop comprehensive plans and policies to protect children. LEVEL OF EVIDENCE: II.

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.