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1.
Malawi Med J ; 33(2): 73-81, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34777702

RESUMO

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.

2.
PLoS One ; 16(1): e0243536, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33406087

RESUMO

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.


Assuntos
Doenças Musculoesqueléticas/epidemiologia , Doenças Musculoesqueléticas/etiologia , Inquéritos e Questionários , Adolescente , Adulto , Criança , Pré-Escolar , Escolaridade , Características da Família , Humanos , Lactente , Recém-Nascido , Malaui/epidemiologia , Pessoa de Meia-Idade , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/terapia , Prevalência , Qualidade de Vida , Padrões de Referência , Índice de Gravidade de Doença , Adulto Jovem
3.
J Surg Res ; 259: 320-325, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33129505

RESUMO

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.


Assuntos
Apendicectomia/efeitos adversos , Apendicite/mortalidade , Falha da Terapia de Resgate/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Perfuração Intestinal/mortalidade , Complicações Pós-Operatórias/mortalidade , Adulto , Apendicectomia/estatística & dados numéricos , Apendicite/complicações , Apendicite/diagnóstico , Apendicite/cirurgia , Feminino , Acesso aos Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/etiologia , Perfuração Intestinal/cirurgia , Malaui/epidemiologia , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária/estatística & dados numéricos , Tempo para o Tratamento/organização & administração , Tempo para o Tratamento/estatística & dados numéricos , Adulto Jovem
4.
Traffic Inj Prev ; 21(8): 527-532, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33064031

RESUMO

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.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Consumo de Bebidas Alcoólicas/epidemiologia , Ferimentos e Lesões/epidemiologia , Adolescente , Adulto , Estudos Transversais , Serviço Hospitalar de Emergência , Feminino , Humanos , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Pedestres/estatística & dados numéricos , Prevalência , Ferimentos e Lesões/terapia
5.
BMC Public Health ; 20(1): 1456, 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32977777

RESUMO

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.


Assuntos
Família , Criança , Estudos Transversais , Feminino , Humanos , Malaui/epidemiologia , Masculino , Prevalência , Inquéritos e Questionários
6.
Injury ; 51(7): 1548-1553, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32456956

RESUMO

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.


Assuntos
Economia Hospitalar , Implementação de Plano de Saúde/economia , Vigilância da População/métodos , Sistema de Registros , Custos e Análise de Custo , Países em Desenvolvimento , Recursos em Saúde , Humanos , Malaui/epidemiologia , Estudos Retrospectivos , Ferimentos e Lesões/epidemiologia
7.
World J Surg ; 44(9): 2927-2934, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32440949

RESUMO

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.


Assuntos
Emprego , Violência/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Adolescente , Adulto , Feminino , Humanos , Relações Interpessoais , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Centros de Traumatologia , Adulto Jovem
8.
Injury ; 51(1): 97-102, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31761427

RESUMO

BACKGROUND: Globally, traumatic injury is a leading cause of morbidity and mortality in low-income countries. However, trauma centers in these environments have limited resources to manage complex trauma with minimal staffing and diagnostic tools. These limitations may be exacerbated at night. We hypothesized that there is an increase in trauma-associated mortality for patients presenting during nighttime hours. METHODS: We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma registry in Lilongwe, Malawi from January 2012 through December 2016. Nighttime was defined as 18:00 until 5:59. Patients brought in dead were excluded. A modified Poisson regression model was used to calculate the relationship between presentation at night and mortality, adjusted for significant confounders. RESULTS: 74,500 patients were included. During the day, crude mortality was 0.8% compared to 1.4% at night (p < 0.001). The risk ratio of mortality following night time presentation compared to day was 1.90 (95% CI 1.48, 2.42) when adjusted for injury severity, assessed by the Malawi Trauma Score (MTS), and transfer status. When stratified by the year of traumatic injury, the risk ratio of death decreased each year from 2012-2014 but increased in 2015. There was no difference in 2016. CONCLUSIONS: We report the first description of diurnal variation in trauma-associated mortality in sub-Saharan Africa. Injured patients who presented at night had nearly twice the adjusted risk ratio of death compared to patients that presented during the daytime although there were yearly differences. Diurnal variation in trauma-associated mortality is a simple but important indicator of the maturity of a trauma system and should be tracked for health care system improvement.


Assuntos
Ritmo Circadiano , Atenção à Saúde/estatística & dados numéricos , Sistema de Registros , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , África ao Sul do Saara/epidemiologia , Criança , Feminino , Humanos , Masculino , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Adulto Jovem
9.
PLoS One ; 14(11): e0224655, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31725746

RESUMO

INTRODUCTION: Epidemiology of acute kidney injury (AKI) is highly dependent on patient characteristics, context and geography. Considering the limited information in Latin America and the Caribbean, we performed a study with the aim to contribute to improve its better understanding. METHODS: Observational, prospective, longitudinal, multinational cohort study addressed to determine risk factors, clinical profile, process of care and outcomes of AKI in the region. Patients meeting KDIGO AKI definition were included over a 9-month period and designated community or hospital-acquired. De-identified clinical and lab data were entered in a specifically designed on-line platform. Co-variables potentially linked to AKI onset, in-hospital and 90-days mortality, were recorded and correlated using a multiple logistic regression model. RESULTS: Fifty-seven physicians from 15 countries provided data on 905 patients, most with acceptable basic needs coverage. Median age 64 (50-74) yrs; most of them were male (61%) and mestizos (42%). Comorbidities were present in 77%. AKI was community-acquired in 62%. Dehydration, shock and nephrotoxic drugs were the commonest causes. During their process of care, 77% of patients were assessed by nephrologists. Kidney replacement therapy (KRT) was performed in 29% of cases. In-hospital mortality was 26.5% and independently associated to older age, chronic liver disease, hypotension, shock, cardiac disturbances, hospital-acquired sepsis, KRT and mechanical ventilation. At 90-days follow up partial or complete renal recovery was 81% and mortality 24%. CONCLUSIONS: AKI was mainly community-acquired, in patients with comorbidities and linked to fluid loss and nephrotoxic drugs. Mortality was high and long-term follow up poor. Notwithstanding, the study shows partially the situation in the participant countries rather than the actual epidemiology of AKI in Latin America and Caribbean, a pending and needed task.


Assuntos
Injúria Renal Aguda/mortalidade , Mortalidade Hospitalar , Terapia de Substituição Renal , Injúria Renal Aguda/terapia , Adolescente , Adulto , Idoso , Região do Caribe/epidemiologia , Intervalo Livre de Doença , Humanos , América Latina/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida
10.
Injury ; 50(9): 1552-1557, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31301812

RESUMO

BACKGROUND: Globally, traumatic injury is a leading cause of morbidity and mortality in low-income countries. Current tools for predicting trauma-associated mortality are often not applicable in low-resource environments due to a lack of diagnostic adjuncts. This study sought to derive and validate a model for predicting mortality that requires only a history and physical exam. METHODS: We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi from 2011 through 2014. Using statistical randomization, 80% of patients were used for derivation and 20% were used for validation. Logistic regression modeling was used to derive factors associated with mortality and the Malawi Trauma Score (MTS) was constructed. The model fitness was tested. RESULTS: 62,354 patients are included. Patients are young (mean age 23.0, SD 15.9 years) with a male preponderance (72%). Overall mortality is 1.8%. The MTS is tabulated based on initial mental status (alert, responds to voice, responds only to pain or worse), anatomical location of the most severe injury, the presence or absence of a radial pulse on examination, age, and sex. The score range is 2-32. A mental status exam of only responding to pain or worse, head injury, the absence of a radial pulse, extremes of age, and male sex all conferred a higher probability of mortality. The ROC area under the curve for the derivation cohort and validation cohort were 0.83 (95% CI 0.78, 0.87) and 0.83 (95% CI 0.75, 0.92), respectively. A MTS of 25 confers a 50% probability of death. CONCLUSIONS: The MTS provides a reliable tool for trauma triage in sub-Saharan Africa and helps risk stratify patient populations. Unlike other models previously developed, its strength is its utility in virtually any environment, while reliably predicting injury- associated mortality.


Assuntos
Mortalidade Hospitalar/tendências , Sistema de Registros/estatística & dados numéricos , Centros de Traumatologia , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Criança , Feminino , Recursos em Saúde , Humanos , Malaui/epidemiologia , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Ferimentos e Lesões/economia , Ferimentos e Lesões/terapia , Adulto Jovem
12.
Appl Biochem Biotechnol ; 189(3): 903-918, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31144254

RESUMO

Interfacial esterases are useful enzymes in bioconversion and racemic mixture resolution processes. Marine invertebrates are few explored potential sources of these proteins. In this work, aqueous extracts of 41 species of marine invertebrates were screened for esterase, lipase, and phospholipase A activities, being all positive. Five extracts (Stichodactyla helianthus, Condylactis gigantea, Stylocheilus longicauda, Zoanthus pulchellus, and Plexaura homomalla) were selected for their activity values and immobilized on Octyl-Sepharose CL 4B support by interfacial adsorption. The selectivity of this immobilization method for interfacial esterases was evidenced by immobilization percentages ≥ 94% in almost all cases for lipase and phospholipase A activities. Six pharmaceutical-relevant esters (phenylethyl butyrate, ethyl-2-hydroxy-4-phenyl-butanoate, 2-oxyranylmethyl acetate (glycidol acetate), 7-aminocephalosporanic acid, methyl-prostaglandin F2α, and methyl-6-metoxy-α-methyl-2-naphtalen-acetate -naproxen methyl ester-) were bioconverted by at least three of these biocatalysts, with the lowest conversion percentage of 24%. In addition, three biocatalysts were used in the racemic mixture resolution of three previous compounds. The S. helianthus-derived biocatalyst showed the highest enantiomeric ratios for glycidol acetate (2.67, (S)-selective) and naproxen methyl ester (8.32, (R)-selective), and the immobilized extract of S. longicauda was the most resolutive toward the ethyl-2-hydroxy-4-phenyl-butanoate (8.13, (S)-selective). These results indicate the relevance of such marine interfacial esterases as immobilized biocatalysts for the pharmaceutical industry.


Assuntos
Organismos Aquáticos/enzimologia , Biocatálise , Enzimas Imobilizadas/química , Enzimas Imobilizadas/metabolismo , Esterases/química , Esterases/metabolismo , Invertebrados/enzimologia , Animais , Ésteres/química , Ésteres/metabolismo , Lipase/metabolismo , Fosfolipases/metabolismo , Estereoisomerismo , Especificidade por Substrato , Água/química
13.
BMC Public Health ; 19(1): 264, 2019 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-30836995

RESUMO

BACKGROUND: It is estimated that nearly five billion people worldwide do not have access to safe surgery. This access gap disproportionately affects low-and middle-income countries (LMICs). One of the barriers to healthcare in LMICs is access to transport to a healthcare facility. Both availability and affordability of transport can be issues delaying access to health care. This study aimed to describe the main transportation factors affecting access and delay in reaching a facility for health care in Malawi. METHODS: This was a multi-stage, clustered, probability sampling with systematic sampling of households for transportation access to general health and surgical care. Malawi has an estimated population of nearly 18 million people, with a total of 48,233 registered settlements spread over 28 administrative districts. 55 settlements per district were randomly selected for data collection, and 2-4 households were selected, depending on the size. Two persons per household were interviewed. The Surgeons Overseas Assessment of Surgical need (SOSAS) tool was used by trained personnel to collect data during the months of July and August 2016. Analysis of data from 1479 households and 2958 interviewees was by univariate and multivariate methods. RESULTS: Analysis showed that 90.1% were rural inhabitants, and 40% were farmers. No formal employment was reported for 24.9% persons. Animal drawn carts prevailed as the most common mode of transport from home to the primary health facility - normally a health centre. Travel to secondary and tertiary level health facilities was mostly by public transport, 31.5 and 43.4% respectively. Median travel time from home to a health centre was 1 h, and 2.5 h to a central hospital. Thirty nine percent of male and 59% of female head of households reported lack financial resources to go to a hospital. CONCLUSION: In Malawi, lack of suitable transport, finances and prolonged travel time to a health care centre, all pose barriers to timely access of health care. Improving the availability of transport between rural health centres and district hospitals, and between the district and central hospitals, could help overcome the transportation barriers to health care.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , População Rural/estatística & dados numéricos , Transportes/estatística & dados numéricos , Adolescente , Adulto , Idoso , Custos e Análise de Custo , Estudos Transversais , Países em Desenvolvimento , Emprego , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Malaui , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos , Inquéritos e Questionários , Fatores de Tempo , Viagem , Adulto Jovem
14.
Rev. argent. reumatol ; 29(4): 30-34, dic. 2018. graf, tab
Artigo em Espanhol | LILACS | ID: biblio-1003294

RESUMO

El objetivo de este estudio fue evaluar la utilidad de la rebiopsia renal en pacientes con glomerulonefritis ANCA en la toma de decisiones. Se incluyeron en forma retrospectiva todos los pacientes con glomerulonefritis ANCA diagnosticados por biopsia renal entre enero de 2002 y mayo de 2017. Se revisó la histología de las rebiopsias y fue correlacionada con los hallazgos clínicos (hematuria, proteinuria y caída del filtrado) y resultados histológicos de la primera y segunda biopsia. Sesenta pacientes (77% mujeres) fueron incluidos. De ellos, 15 (25%) fueron sometidos a una rebiopsia durante el seguimiento. La media de tiempo hasta la rebiopsia fue de 38,4 meses (DS 20,4). En el grupo de rebiopsia, la presencia de hematuria, proteinuria y caída del filtrado glomerular se observó en el 73%, 73% y 60% de pacientes, respectivamente. No encontramos una correlación entre las lesiones activas (semilunas, necrosis) con la presencia de hematuria o caída del filtrado glomerular. En un gran porcentaje, la histología renal mostró progresión en términos de cronicidad y con menor frecuencia lesiones de actividad. A pesar de esto, en el 67% de los pacientes se realizó un cambio de tratamiento, iniciando una nueva terapia de inducción, alcanzando una respuesta renal en el 85% de los casos.


The aim of this study was to evaluate usefulness of renal re-biopsy in patients with ANCA glomerulonephritis in treatment decisions. We included retrospectively all patients with biopsy-proven ANCA glomerulonephritis between January 2002 and May 2017. We analysed patient's baseline characteristics at the time of re-biopsy, presence of microscopic hematuria, proteinuria and/or decline in glomerular filtration rate (GFR) and time to renal relapse/rebiopsy. Data of physicians' decisions after rebiopsy was collected. 60 patients (77% females) were included. Of those, 15 (25%) underwent renal re-biopsy during the follow up based on clinical manifestations. Mean time until re-biopsy was 38.4 months (SD 20.4). In the re-biopsy group, 73% of patients had new onset hematuria, 73% had new onset or worsening proteinuria (40% and 33% respectably), and 60% had decline in the GFR. When analysing histological changes in the repeat biopsy we didn't find a correlation between active lesions (crescents, necrosis etc.) and hematuria. All patients that underwent repeat biopsy were considered to be active but renal histology showed progression in terms of chronicity and rare active histological lesions. Despite this, in 67% of patients, physicians made a treatment change, initiating a new induction therapy regimen and achieving renal response in 85% of patients.


Assuntos
Vasculite , Biópsia , Glomerulonefrite
15.
Trop Doct ; 48(4): 316-322, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30139306

RESUMO

This was a retrospective review of all children aged ≤16 who were treated in the casualty department at the central hospital in Lilongwe, Malawi, between 1 January 2009 and 31 December 2015. A total of 4776 children were treated for road traffic injuries (RTIs) in the study period. There was an increase in incidence from 428 RTIs in 2009 to a maximum of 834 in 2014. Child pedestrians represented 53.8% of the injuries, but 78% of deaths and 71% of those with moderate to severe head injuries. Pedestrians were mostly injured by cars (36%) and by large trucks, buses and lorries (36%). Eighty-four (1.8%) children were brought in dead, while 40 (0.8%) children died in the casualty department or during their hospital stay. There has been a drastic increase of RTIs in children in Lilongwe, Malawi. Child pedestrians were most affected, both in terms of incidence and severity.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Acidentes de Trânsito/mortalidade , Acidentes de Trânsito/prevenção & controle , Adolescente , Criança , Pré-Escolar , Traumatismos Craniocerebrais/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Lactente , Tempo de Internação/estatística & dados numéricos , Malaui/epidemiologia , Masculino , Estudos Retrospectivos , Ferimentos e Lesões/etiologia
17.
Trauma Surg Acute Care Open ; 3(1): e000252, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30687785

RESUMO

Background: The contribution of interpersonal violence (IPV) to trauma burden varies greatly by region. The high rates of IPV in sub-Saharan Africa are thought to relate in part to the high rates of collective violence. Malawi, a country with no history of internal collective violence, provides an excellent setting to evaluate whether collective violence drives the high rates of IPV in this region. Methods: This is a retrospective review of a prospective trauma registry from 2009 through 2016 at Kamuzu Central Hospital in Lilongwe, Malawi. Adult (>16 years) victims of IPV were compared with non-intentional trauma victims. Log binomial regression determined factors associated with increased risk of mortality for victims of IPV. Results: Of 72 488 trauma patients, 25 008 (34.5%) suffered IPV. Victims of IPV were more often male (80.2% vs. 74.8%; p<0.001), younger (median age: 28 years (IQR: 23-34) vs. 30 years (IQR: 24-39); p<0.001), and were more often admitted at night (47.4% vs. 31.9%; p<0.001). Of the IPV victims, 16.5% admitted alcohol use, compared with only 4.4% in other trauma victims (p<0.001). In regression modeling, compared with extremity injuries, head injuries (3.14, 2.24-4.39; p<0.001) and torso injuries (4.32, 2.98-6.27; p<0.001) had increased risk of mortality. Compared with other or unknown mechanisms, penetrating injuries also had increased risk of mortality (1.46, 95% CI 1.17 to 1.81, p=0.001). Alcohol use was associated with a lower risk of mortality (0.54, 95% CI 0.39 to 0.75; p<0.001). Discussion: Even in a sub-Saharan country that never experienced internal collective violence, IPV injury rates are high. Public health efforts to measure and address alcohol use, and studies to determine the role of "mob justice," poverty, and intimate partner violence in IPV, in Malawi are needed. Level of evidence: Level III.

18.
World J Surg ; 41(12): 3031-3037, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29018914

RESUMO

INTRODUCTION: To address the need for more surgical providers in low-resource settings, a collaboration to create a surgical residency-training program for local Malawian physicians was established in 2009. This study sought to describe the short-term independent effect of a surgical residency program on trauma mortality at a tertiary trauma center in sub-Saharan Africa. METHODS: We conducted a retrospective analysis of all patients recorded in the trauma surveillance registry of Kamuzu Central Hospital in Lilongwe, Malawi, from 2009 (three residents) through 2014 (11 residents). Log-binominal regression modeling was used to compare the risk ratio of death compared to the referent year of 2009, when the program was started, after adjusting for relevant covariates. Primary injury type was used as a surrogate for injury severity. RESULTS: In total, 82,534 patients were recorded into the KCH Trauma Registry during the study period. Mean age was 23.1 years (SD 15.7) with a male preponderance (72.1%). Trauma patient volume increased from 8725 patients in 2009 to 15,998 patients in 2014. Each year had a significantly decreased risk of death compared to 2009 when adjusted for primary injury type, age, and gender, with an adjusted risk ratio of 0.73 (95% CI 0.58, 0.90) in 2010 and 0.52 (95% CI 0.43, 0.62) in 2014. CONCLUSION: The global burden of surgical diseases cannot be attenuated in the presence of an inadequate surgical workforce. After institution of a surgery residency program, adjusted injury-associated mortality decreased each year despite substantial increases in trauma patient volume. In low-resource settings, establishment of a surgical residency program significantly improves trauma-associated outcomes.


Assuntos
Internato e Residência , Cirurgiões/provisão & distribuição , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Distribuição por Idade , Feminino , Humanos , Malaui/epidemiologia , Masculino , Sistema de Registros , Análise de Regressão , Estudos Retrospectivos , Distribuição por Sexo , Centros de Traumatologia , Traumatologia/educação , Recursos Humanos , Ferimentos e Lesões/epidemiologia
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