Malawi Medical Journal最新文献

A challenge for the health system in Malawi is that funding allocation is heavily influenced by donor priorities. As a result, mandated routine elements of service delivery may not be fully offered owing to lack of resources or programmatic priority. Integration of currently active 'vertical' programmes (those focused on a specific priority disease entity) into existing 'horizontal' services (meaning provision across the range of clinical and public health need) has potential to improve access and quality of service delivery for Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) in Malawi. We identified and tabulated the main vertical funding streams currently available in Malawi and identified where these could intersect with existing horizontal health sector programmes in order to strengthen RMNCAH. We have indicated how each of the main vertical programmatic components can be adapted and integrated to support broader system strengthening within RMNCAH focusing especially on drug and commodity procurement, supply chain logistics, health facility and equipment maintenance/upgrading, health service activity data systems, human resources for 'front line' RMNCAH provision, as well as community engagement and mobilization. By circumventing the various limitations of vertical programmes in the delivery of health services in the country, they would complement existing funding streams rather than operating in a vacuum as independent activities. We therefore recommend the integration of horizontal and existing vertical programmes in order to improve RMNCAH in Malawi.

Angina bullosa haemorrhgica is a relatively uncommon condition characterized by blood-filled subepithelial lesions in the oral mucosa that is idiopathic and not caused by a systemic disease or a hemostatic abnormality. Middle-aged and elderly patients are usually affected and lesions heal spontaneously without scarring. A rapidly expanding hemorrhagic blister in the oropharynx can induce upper airway obstruction, so recognizing the lesion as soon as possible is essential. Because of its rarity, we wanted to highlight a 42-year-old male patient who presented with hemorrhagic bullae associated with insignificant local trauma in the oral mucosa and to emphasize that Angina bullosa haemorrhagica is a rare but recognizable lesion that clinicians should be aware of.

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.

Background: Children with clefts lips often present with cardiac abnormalities, among them the tetralogy of Fallot. Anaesthesia for patients with unrepaired Tetralogy of Fallot coming for a non-cardiac surgery represents an additional risk of increased perioperative morbidity and mortality.

Case presentation: We present a case of a 8 years old boy with unrepaired Tetralogy of Fallot scheduled for cleft lip repair. The Child was referred to Mercy James Centre for Paediatric Surgery and Intensive Care from an Operation Smile Mission campaign. Anaesthesia consisted of a balanced general anaesthesia combined with regional anaesthesia by an infraorbital nerve block. The child developed hypercyanotic spells postoperatively which were successfully managed with noradrenaline, morphine, fluid, and oxygen therapy.

Conclusion: Children with unrepair Tetralogy of Fallot coming for non-cardiac surgery have increased risk of complications during anaesthesia. The anaesthesia provider should be aware and ready to manage them promptly.

Background: Pragmatic clinical trials generally rely on real world data and have the potential to generate real world evidence. This approach arose from concerns that many trial results did not adequately inform real world practice. However, maintaining the real world setting during the conduct of a trial and ensuring adequate protection for research participants can be challenging. Best practices in research oversight for pragmatic clinical trials are nascent and underdeveloped, especially in developing countries.

Methods: We use the PRECIS-2 tool to present a case study from Lilongwe in Malawi to describe ethical and regulatory challenges encountered during the conduct of a pragmatic trial and suggest possible solutions.

Results: In this article, we highlight the following six issues: (1) one public facility hosting several pragmatic trials within the same period; (2) research participants refusing financial incentives; (3) inadequate infrastructure and high workload to conduct research; (4) silos among partner organisations involved in delivery of health care; (5) individuals influencing the implementation of revised national guidelines; (6) difficulties with access to electronic medical records.

Conclusion: Multiple stakeholder engagement is critical to the conduct of pragmatic trials, and even with careful stakeholder engagement, continuous monitoring by gatekeepers is essential. In the Malawian context, active engagement of the district research committees can complement the work of the research ethics committees (RECs).

Visceral artery aneurysm, especially splenic artery aneurysm, is rare and is usually associated with pregnancy. When such aneurysms rupture, they can be fatal, and they often require emergency surgery. This case report includes a review of the literature and describes a effective multidisciplinary approach to managing this type of aneurysm. We describe the treatment of a ruptured splenic artery aneurysm and the careful coordination of obstetric, vascular surgery, and intensive care teams. The uniqueness of this case arose from the metal embolization coil that was found to have fallen off from a recently embolized ruptured splenic artery aneurysm. The management of this ruptured splenic artery aneurysm and iatrogenic foreign body insult required a combination of multiple specialties to provide life-saving treatment. Such cases should be managed by multidisciplinary teams if institutional resources allow for it.

Background: Perinatal depression is a common and disabling mental health problem in Malawi and other Low- and middle-income countries. There is evidence for effective psychosocial interventions for perinatal depression, but no such intervention has been developed for use in Malawi. The broad aim of this study was to explore the cultural appropriateness of a psychosocial intervention for perinatal depression called the Thinking Healthy Programme-Peer delivered for adaptation and use in Lilongwe, Malawi.

Methods: A qualitative exploratory design was used. Data were collected through conducting five Focus Group Discussions, involving thirty-eight purposefully selected participants including pregnant women, community volunteers and their supervisors, the Health Surveillance Assistants and maternal health care workers at implementation and policy level following observations of video recorded role plays of the Thinking Healthy Programme-Peer delivered sessions in theatre testing. A content analysis approach was used to analyse data.

Results: Six main themes were generated regarding the appropriateness of the content and delivery of the Thinking Healthy Programme-Peer delivered intervention, including: 1) Focus of the intervention; 2) Cultural appropriateness of the content; 3) Language used; 4) Context; 5) Provider of the intervention; and 6) Flexibility in the delivery of the intervention. The Thinking Healthy Programme-Peer delivered intervention was deemed appropriate for the target population, though with recommendations to: review illustrations to enhance clarity, use culturally appropriate stories and idioms, use daily spoken language, and adapt the number and duration of sessions to meet the needs of individual clients.

Conclusions: These findings highlight important areas to inform adaptation of the Thinking Healthy Programme-Peer delivered and add to the growing evidence of cultural adaptation of psychosocial interventions for perinatal depression.

This special communication discusses the current legal and ethical requirements for informed consent to medical treatment of adults in Malawi. It analyzes the scope of the laws and code of ethics on professional discipline, including criminal privilege for surgeries and clarifies when insufficient disclosures entitle patients to compensation under civil law. Inconsistencies and uncertainties in the law are made apparent. It evaluates to which degree disclosure standards of other Commonwealth jurisdictions (e.g. the case of Montgomery) would be suitable for the health care setting of a country like Malawi that is characterized by shortages of resources, high illiteracy rates and a communitarian cultural context. Doctor-patient communication is not alien to African culture and part of sufficient informed consent. In order to balance the need for efficiency in health care delivery, accountability for quality care, fairness and effective patient-doctor communication the authors suggest to adopt the reasonable patient test only, if a defence of heavy workload on case-to-case basis is introduced at the same time. This does not dispense the need for organisational diligence on part of the institutional health care provider within its capacity.

Aim: The presence and frequency of surgical complications indicate the quality of the surgery performed. However, a standard classification system should specify, describe, and compare complications. Clavien Dindo classification is an easily applicable classification in the evaluation of complications. Our study aimed to reveal the severity of complications and the factors affecting them by using the Clavien Dindo classification in patients undergoing laparoscopic colorectal surgery.

Methods: Between January 2015 and December 2020, we retrospectively collected the laparoscopic colorectal surgery complications using Clavien Dindo grading in patients in our colorectal surgery unit in the database. The outcome variables studied were age, gender, BMI, ASA score, postoperative length of hospital stay, operation procedure, cancer size, postoperative mortality.

Results: There were 53 males and 17 female patients, with a mean age of 56,9±13,4.(19-81). Seventy patients, 32 (45%), had at least one postoperative complication. About complications; 58.6% were rated as Clavien I, 22.9% as Clavien II, 8.6% as Clavien IIIa, 4.3% as Clavien IIIb, 2.9% as Clavien IVa, and 2.9% as Clavien V. There was no Clavien grade IVb complication in any of the patients. Length of hospital stays was significantly higher in patients with had major complex surgery and had higher scores. Clavien Dindo classification was positively statistically significantly related to the day of hospitalization in male and female sex (p<0.001 for all). In addition, positively significantly related to Clavien Dindo classation and tumor diameter in the female sex (p=0.014) detected.

Conclusions: In laparoscopic colorectal surgery, the Clavien-Dindo classification can be easily applied and used safely to determine complication rates. The reason for this statistical difference that we detected in our study and that occurs in women may be due to anatomical differences or the surgeon's experience.

Background: The burden of surgical complications from unsafe abortion affects both health facilities and patients in most developing countries. This study aimed to determine the nature of surgical complications from unsafe abortion treated at the JFKMC, Liberia, and the estimated cost burden on facility and patient.

Method: This was a retrospective study of the medical records of patients who had exploratory laparotomy for complications of induced abortion and presented at the JFKMC from June 15, 2018, to December 15, 2019.

Results: The medical records of 44 out of the 49 patients who had exploratory laparotomy for unsafe abortion were captured and analyzed. Surgical complications from unsafe abortion accounted for 17.8% out of the 276 gynaecological surgeries at the JFKMC, Liberia. The case fatality was 22.4%. The mean age of subjects was 29.00 ±6.06 years. About 1/3 of the subjects were in their teens, over 4/5 were single, and half were students. Almost 60.0% of the subjects terminated their pregnancies in private health facilities. Ten subjects had a hysterectomy for necrotic/septic uterus. The mean cost of managing a patient with surgical complications from unsafe abortion at the JFKMC was $331.50, in contrast with $22.00, for spontaneous or induced abortion with mild complications treated as a day case.

Conclusion: This study showed a cost burden on the facility, and patients as a result of surgical complications from induced abortion. A shift in current practice by health facilities in Liberia to medical management of abortion and MVA, training of health personnel on the use of MVA, and a less restrictive abortion law with effective contraceptive services are recommended.