Establishment of trauma registry at Queen Elizabeth Central Hospital(QECH), Blantyre, Malawi and mapping of high risk geographic areas for trauma

BACKGROUND: Less attention is directed toward gaining a better understanding of the burden and prevention of injuries, in low and middle income countries(LMICs). We report the establishment of a trauma registry at the Adult Emergency and Trauma Centre(AETC) at Queen Elizabeth Central Hospital(QECH) in Blantyre, Malawi and identify high risk geographic areas. METHODS: We devised a paper based two-page trauma registry form. Ten data clerks and all AETC clinicians were trained to complete demographic and clinical details respectively. Descriptive data, regression and hotspot analyses were done using STATA 15 statistical package and ArcGIS(16) software respectively.RESULTS: There were 3,747 patients from May 2013 to May 2015. The most common mechanisms of injury were assault(38.2%), and road traffi c injuries(31.6%). The majority had soft tissue injury(53.1%), while 23.8% had no diagnosis indicated. Fractures(OR 19.94 [15.34–25.93]), head injury and internal organ injury(OR 29.5 [16.29–53.4]), and use of ambulance(OR 1.57 [1.06–2.33]) were found to be predictive of increased odds of being admitted to hospital while assault(OR 0.69 [0.52–0.91]) was found to be associated with less odds of being admitted to hospital. Hot spot analysis showed that at 99% confidence interval, Ndirande, Mbayani and Limbe were the top hot spots for injury occurrence. CONCLUSION: We have described the process of establishing an integrated and potentially sustainable trauma registry. Signifi cant data were captured to provide details on the epidemiology of trauma and insight on how care could be improved at AETC and surrounding health facilities. This approach may be relevant in similar poor resource settings.

Associative Factors for Birth Asphyxia at Queen Elizabeth Central Hospital—Malawi

Background: Birth asphyxia is one of the major causes of neonatal deaths worldwide. Queen Elizabeth Central Hospital (QECH) neonatal ward records indicate that 36.5% of neonates admitted in the ward from April to September 2012 had birth asphyxia. This study was conducted to explore associative factors for birth asphyxia at QECH. Methodology: The study design was descriptive cross sectional that employed quantitative methods of data collection and analysis. Data sources were case notes of neonates and their mothers.? Sample size was 87 neonates with birth asphyxia and 87 neonates admitted with conditions other than birth asphyxia as controls. Data were collected from November to December 2013. Statistical Package for Social Science (SPSS) version16.0 was used to analyze data. Results: Findings revealed that there were no maternal associative factors for birth asphyxia, however, foetal distress, prolonged first and second stage of labour were significant associative factors for birth asphyxia. Conclusion: Associative factors for birth asphyxia at QECH are Foetal distress, prolonged first and second stage of labour. These factors can be prevented if quality care is provided to women in labour through close monitoring of foetal heart, appropriate use of the partograph, prompt decision making and early interventions.

Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy

BACKGROUND Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer,but we have experienced resistance to the introduction of the FreeHandffrobotic camera holder to augment laparoscopic colorectal surgery.AIM To compare the initial results between conventional and FreeHandffrobot-assisted laparoscopic colectomy in Trinidad and Tobago.METHODS This was a prospective study of outcomes from all laparoscopic colectomies per-formed for colorectal carcinoma from November 29,2021 to May 30,2022.The following data were recorded:Operating time,conversions,estimated blood loss,hospitalization,morbidity,surgical resection margins and number of nodes har-vested.All data were entered into an excel database and the data were analyzed using SPSS ver 20.0.RESULTS There were 23 patients undergoing colectomies for malignant disease:8(35%)FreeHandff-assisted and 15(65%)conventional laparoscopic colectomies.There were no conversions.Operating time was significantly lower in patients under-going robot-assisted laparoscopic colectomy(95.13±9.22 vs 105.67±11.48 min;P=0.045).Otherwise,there was no difference in estimated blood loss,nodal harvest,hospitalization,morbidity or mortality.CONCLUSION The FreeHandffrobot for colectomies is safe,provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.

Geospatial Variability of Cholera Cases in Malawi Based on Climatic and Socioeconomic Influences

Cholera remains a public health threat in most developing countries in Asia and Africa including Malawi with seasonal recurrent outbreaks. Malawi’s recent Cholera outbreak in 2022 and 2023, exhibited higher morbidity and mortality rates than the past two decades. Lack of spatiotemporal-based technology and variability assessment tools in Malawi’s Cholera monitoring and management, limit our understanding of the disease’s epidemiology. The present work developed a spatiotemporal variability model for Cholera disease at district level and its relationship to socioeconomic and climatic factors based on cumulative confirmed Cholera cases in Malawi from March 2022 to July 2023 using Z-score statistic and multiscale geographically weighted regression (MGWR) in a Geographical Information System (GIS). We found out that socioeconomic factors such as access to safe drinking water, population density and poverty level, and climatic factors including temperature and rainfall strongly influenced Cholera prevalence in a complex and multifaceted manner. The model shows that Lilongwe, Mangochi, Blantyre and Balaka districts were highly vulnerable to Cholera disease followed by lakeshore districts of Salima, Nkhotakota, Nkhata-Bay and Karonga than other districts. We recommend strategic measures such as Water, Sanitation, and Hygiene (WASH) interventions, community awareness on proper water storage, Cholera case management, vaccination campaigns and spatial-based surveillance systems in the most affected districts. This research has shown that MGWR, as a surveillance system, has the potential of providing insights on the disease’s spatial patterns for public health authorities to identify high-risk districts and implement early response interventions to reduce the spread of the disease.

Liver biopsy in a district general hospital:Changes over two decades

瞄准：在英国在一所区域综合医院在二十年学习肝活体检视实践。方法：我们识别了从辐射学和肠胃病学部门的数据库有在 1986 和 2006 之间的至少一肝活体检视的所有病人。有不完全的临床的数据的题目从学习被排除。结果：103 肝活体检视的一个总数被执行。临床的数据为 88 个病人是可得到的，与 95 活体检视。在 1986 和 1996 之间，(95%) 18 从活体检视执行了的 19 肝是盲目的，(33%) 6 为主要胆汁性肝硬变。在 1996 和 2006 之间，(18%) 14 从 76 活体检视是盲目的；并且指示是反常的肝测试(33%) ，丙肝(12%) 和目标活体检视(11%) 。肝活体检视在 5 是不起帮助作用的(5%) 题目。疼痛是肝活体检视(5%) 的最普通的复杂并发症。没有活体检视相关的死亡被报导。与盲目活体检视技术向更技术的失败和复杂并发症有一个趋势。结论：在小区域医院里执行的肝活体检视为安全、有用诊断并且阶段目的。反常的肝测试，非酒精的脂肝疾病和指向的活体检视是逐渐地普通的指示。指导超声的肝活体检视现在是比较喜欢的方法并且与更少复杂并发症被联系。

Missed opportunities for hepatitis C treatment at a tertiary care hospital in South Australia

BACKGROUND Hepatitis C is a global epidemic and an estimated 230000 Australians were living with chronic hepatitis C in 2016.Through effective public health policy and state commitment,Australia has utilised the advent of direct acting antiviral(DAA)therapy to transform the therapeutic landscape for hepatitis C virus(HCV).However,treatment rates are falling and novel public health approaches are required to maintain momentum for HCV elimination.Contemporary discourse in cascades of care have focused on expanding testing capabilities but less attention has been given to linking previously diagnosed patients back to care.Our simple and focused study rests on the premise that hospital admissions are an excellent opportunity to identify and refer previously diagnosed patients for HCV treatment.AIM To assess whether inpatients with HCV are appropriately referred on for treatment.METHODS We conducted a retrospective single centre cohort study that examined all patients with HCV presenting to The Queen Elizabeth Hospital(QEH)inpatient service between January 1 and December 31,2017.QEH is a tertiary care hospital in South Australia.The main inclusion criteria were patients with active HCV infection who were eligible for DAA therapy.Our study cohort was identified using a comprehensive list of diagnosis based on international classification of diseases-10 AM codes for chronic viral hepatitis.Patients were excluded from the analysis if they had previously received DAA therapy or spontaneously cleared HCV.Patients presenting with decompensated liver cirrhosis or other systemic medical conditions conferring poor short-term prognosis were also excluded from the analysis.The primary outcome of our study was referral of patients for HCV treatment.Secondary outcomes included assessment of factors predicting treatment referral.RESULTS There were 309 inpatients identified with hepatitis C as a principal or additional diagnosis between January 1 and December 31,2017.Of these patients,148 had active HCV infection without prior treatment or spontaneous clearance.Overall,131 patients were deemed eligible for DAA treatment and included in the main analysis.Mean patient age was 47.75±1.08 years,and 69%of the cohort were male and 13%identified as Aboriginal or Torres Strait Islander.Liver cirrhosis was a complication of hepatitis C in 7%of the study cohort.Only 10 patients were newly diagnosed with HCV infection during the study period with the remainder having been diagnosed prior to the study.CONCLUSION Under 25%of hepatitis C patients presenting to an Australian tertiary hospital were appropriately referred for treatment.Advanced age,cirrhosis and admission under medical specialties were predictors of treatment referral.

Comparison of Nurses’ and Families’ Perception of Family Needs in Critical Care Unit at Referral Hospitals in Malawi

This study compared needs of family members as perceived by nurses and the family members themselves. The study design was descriptive and utilized quantitative data collection and analysis method. Nurses (n = 62) working in the Intensive Care Units (ICU) and High Dependency Units (HDU) of three tertiary health facilities in Malawi at the time of the study consented to participate in the study. In addition, family members (n = 62) who were looking after a critically sick relative in the ICU and HDU in the same tertiary facilities consented and participated in the study. Data were collected using a questionnaire developed from the Critical Care Family Needs Inventory for a period of 7 days. STATA version 10 was used to analyze data. The rank correlation between the mean scores of perceived needs across major need categories of support, comfort, information, proximity and assurance between the nurses and family members was significantly different from zero (r = 0.97, p = 0.005). Nurses and family members, respectively ranked assurance (90% and 92%) as the highest priority need, followed by information (78% and 85%) and comfort (78% and 84%) and then support (70% and 73%) and proximity (66% and 69%). The ranking however between the 2 groups on 16 out of 45 individual needs were significantly different (p < 0.05). Among the nurses, the rankings by registered nurses were significantly higher (p < 0.05) from those of nurse midwife technicians. There were also significant differences (p < 0.05) in the mean scores between the gender of family members with men demanding more “comfort” than females. Results show a need for facility authorities to formulate ICU policies and strategies that ensure provision of friendly services to family members of critically ill patients.

Quality of colonoscopy performed by medical or surgical specialists and trainees in five Australian hospitals

BACKGROUND Ensuring colonoscopy procedure quality is vital to the success of screening and surveillance programmes for bowel cancer in Australia. However, the data on the performance of quality metrics, through adequate adenoma detection, bowel preparation, and procedure completion rates, in the Australian public sector is limited. Understanding these can inform quality improvement to further strengthen our capacity for prevention and early detection of colorectal cancer.AIM To determine the quality of colonoscopy in Australian teaching hospitals and their association with proceduralist specialty, trainee involvement, and location.METHODS We retrospectively evaluated 2443 consecutive colonoscopy procedure reports from 1 January to 1 April, 2018 from five public teaching tertiary hospitals in Australia(median 60 years old, 49% male). Data for bowel preparation quality,procedure completion rates, and detection rates of clinically significant adenomas, conventional adenomas, and serrated lesions was collected and compared to national criteria for quality in colonoscopy. Participating hospital, proceduralist specialty, and trainee involvement indicators were used for stratification. Data was analysed using Chi-squared tests of independence, MannWhitney U, One-way ANOVA, and multivariate binary logistic regression.RESULTS Fifty-two point two percent(n = 1276) and 43.3%(n = 1057) were performed by medical and surgical proceduralists respectively, whilst 29.8%(n = 728) involved a trainee. Inadequate bowel preparation affected 7.3% of all procedures. The procedure completion rate was 95.1%, which increased to 97.5% after adjustment for bowel preparation quality. The pooled cancer, adenoma, and serrated lesion detection rates for all five hospitals were 3.5%, 40%, and 5.9% respectively. Assessed hospitals varied significantly by patient age(P < 0.001), work-force composition(P < 0.001), adequacy of bowel preparation(P < 0.001), and adenoma detection rate(P < 0.001). Two hospitals(40%) did not meet all national criteria for quality, due to a procedure completion rate of 94.5% or serrated lesion detection rate of 2.6%. Although lower than the other hospitals, the difference was not significant. Compared with surgical specialists, procedures performed by medical specialists involved older patients [65 years(inter-quartile range, IQR 58-73) vs 64 years(IQR 56-71);P = 0.04] and were associated with a higher adenoma detection rate [odds ratio(OR) 1.53;confidence interval: 1.21-1.94;P < 0.001]. Procedures involving trainee proceduralists were not associated with differences in the detection of cancer, adenoma, or serrated lesions, compared with specialists, or according to their medical or surgical background. On multivariate analysis, cancer detection was positively associated with patient age(OR 1.04;P < 0.001) and negatively associated with medical compared to surgical proceduralists(OR 0.54;P = 0.04). Conventional adenoma detection rates were independently associated with increasing patient age(OR 1.04;P < 0.001), positively associated with medical compared to surgical proceduralists(OR 1.41;P = 0.002) and negatively associated with male gender(OR 0.53;P < 0.001).CONCLUSION Significant differences in the quality of colonoscopy in Australia exist, even when national benchmarks are achieved. The role of possible contributing factors, like procedural specialty and patient gender need further evaluation.

Machine perfusion and the prevention of ischemic type biliary lesions following liver transplant:What is the evidence?

The widespread uptake of different machine perfusion(MP)strategies for liver transplant has been driven by an effort to minimize graft injury.Damage to the cholangiocytes during the liver donation,preservation,or early posttransplant period may result in stricturing of the biliary tree and inadequate biliary drainage.This problem continues to trouble clinicians,and may have catastrophic consequences for the graft and patient.Ischemic injury,as a result of compromised hepatic artery flow,is a well-known cause of biliary strictures,sepsis,and graft failure.However,very similar lesions can appear with a patent hepatic artery and these are known as ischemic type biliary lesions(ITBL)that are attributed to microcirculatory dysfunction rather than main hepatic arterial compromise.Both the warm and cold ischemic period duration appear to influence the onset of ITBL.All of the commonly used MP techniques deliver oxygen to the graft cells,and therefore may minimize the cholangiocyte injury and subsequently reduce the incidence of ITBL.As clinical experience and published evidence grows for these modalities,the impact they have on ITBL rates is important to consider.In this review,the evidence for the three commonly used MP strategies(abdominal normothermic regional perfusion[A-NRP],hypothermic oxygenated perfusion[HOPE],and normothermic machine perfusion[NMP])for ITBL prevention has been critically reviewed.Inconsistencies with ITBL definitions used in trials,coupled with variations in techniques of MP,make interpretation challenging.Overall,the evidence suggests that both HOPE and A-NRP prevent ITBL in donated after circulatory death grafts compared to cold storage.The evidence for ITBL prevention in donor after brain death grafts with any MP technique is weak.

Investigation of serum calcium and vitamin D levels in superior semicircular canal dehiscence syndrome: A case control study

Objective: It remains unknown whether calcium metabolism has any effect on the clinical presentation of superior semicircular canal dehiscence(SSCD). Our aim was to analyse the adjusted calcium and vitamin D levels in SSCD patients compared to a control group.Methods: This was a prospective case-control study performed in a tertiary referral center, university teaching hospital in the UK. It included all new patients with SSCD seen in a dedicated skull base clinic over a 5-year period(2015-2019) compared to a gender and age matched control group. The main outcome of the study was adjusted calcium and Vitamin D levels between the two groups.Results: A total of 31 SSCD patients were recruited with a matched number of control patients. The mean Vitamin D level on the SSCD group was 44.8 nmoL/l(SD: 20.8) compared to 47.5 nmoL/l(SD: 27.4) on the control group(p = 0.702). Mean Adjusted calcium level was 2.34 mmoL/l(SD: 0.7) for SSCD compared to2.41 mmoL/l(SD: 0.11) for controls(p = 0.01), being within normal limits for both the SSCD and the control group.Conclusion: Our study did not identify a link between Vitamin D levels and presence of SSCD. Normal adjusted calcium values were found in both groups. Despite that a statistically significant lower calcium level was found in the SSCD group which could indicate that suboptimal levels of calcium may affect the micro-environment of the otic capsule at the SSC region.

Resection of isolated liver oligometastatic disease in pancreatic ductal adenocarcinoma:Is there a survival benefit?A systematic review

BACKGROUND Presence of liver metastatic disease in pancreatic ductal adenocarcinoma(PDAC),either synchronous or metachronous after pancreatic resection,is a terminal diagnosis that warrants management with palliative intent as per all international practice guidelines.However,there is an increasing interest on any potential value of surgical treatment of isolated oligometastatic disease in selected cases.AIM To present the published evidence on surgical management of PDAC liver metastases,synchronous and metachronous,and compare the outcomes of these treatments to the current standard of care.METHODS A systematic review was performed in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to compare the outcomes of both synchronous and metachronous liver metastases resection to standard care.RESULTS 356 studies were identified,31 studies underwent full-text review and of these 10 were suitable for inclusion.When synchronous resection of liver metastases was compared to standard care,most studies did not demonstrate a survival benefit with the exception of one study that utilised neoadjuvant treatment.However,resection of metachronous disease appeared to confer a survival advantage when compared to treatment with chemotherapy alone.CONCLUSION A survival benefit may exist in resection of selected cases of metachronous liver oligometastatic PDAC disease,after disease biology has been tested with time and systemic treatment.Any survival benefit is less clear in synchronous cases;however an approach with neoadjuvant treatment and consideration of resection in some selected cases may confer some benefit.Future studies should focus on pathways for selection of cases that may benefit from an aggressive approach.

Case Report of Combined Sixth and Twelfth Cranial Nerve Palsy: A Rare Case of Clival Syndrome Arising from Thymoma

Godtfredsen syndrome or clival syndrome is a rare syndrome of abducens and hypoglossal nerve palsies (cranial nerve 6th and 12th respectively) that localizes to a clival mass. There are few reported cases of this clinical presentation. The aim of this case report is to describe this rare manifestation observed in a woman with clival metastases arising from a thymoma. A previously well 34-year-old native lady presented to a district hospital in Sabah, Malaysia, with history of blurring of vision and headache for 1 month. Cranial nerve examination reveals right abducens nerve palsy (right 6th CN) and right hypoglossal nerve palsy (right 12th CN). Initial imaging with CT brain reveals a subtle extra-axial hyperdense mass adjacent to the clivus and a routine chest x-ray reveals a mediastinal mass. Further imaging of thorax showed right anterior mediastinal mass, which then proceeded with Video-Assisted Thoracoscopic Surgery (VATS) guided biopsy. The biopsy result was consistent with the finding of thymoma, type B2. She was then diagnosed with aggressive form of thymoma, which unfortunately has metastasized to the bone, lung, liver and brain. Despite prognosis at the time of diagnosis is guarded, she still opted to undergo chemotherapy. Despite the completion of 6 cycles of chemotherapy, her disease progressed, and she eventually succumbed to the illness. In short, the presence of combined 6th and 12th palsy should alert clinician to the possibility of clival mass or metastases and hence could earlier workup with appropriate imaging can lead to earlier diagnosis and better treatment outcome.

端粒酶逆转录酶在结肠癌组织中表达的临床意义

背景与目的:尽管能够在70%～90%的恶性肿瘤细胞中可检测到端粒酶活性,但其活性与恶性肿瘤患者预后的关系仍存在争议。本研究旨在探讨端粒酶逆转录酶(humantelomerasereversetranscriptase,hTERT)在结肠癌组织中表达的临床意义。方法:用定量实时RT-PCR检测59例大肠癌标本的癌组织和癌旁非癌组织hTERT表达。结果:癌组织和癌旁非癌组织hTERT表达与临床病理学特征无相关性。32例DukesA和B期患者中,18例(56%)癌组织hTERT表达低于0.6,14例(44%)表达高于0.6,前者的预后较后者好。20例(62%)癌组织/癌旁非癌组织hTERT表达差异低于0.5,12例(38%)表达差异高于0.5,前者的预后较后者好。27例DukesC和D期患者中,癌组织hTERT表达和癌组织/癌旁非癌组织hTERT表达差异对预测患者的预后无意义。结论:结肠癌组织hTERT表达和癌组织/癌旁非癌组织hTERT表达差异可作为DukesA和B期结肠癌患者预后的指标之一。

癌症相关遗传变异的新进展及其在诊断研发中的意义

＂了解更多癌症相关的遗传变异可能有助于癌症的预防和早期诊断,以及为癌症个体化诊断和治疗方案开辟新途径。＂

miRNAs作为癌症预测和预后标志物的巨大潜能

“因为不同癌症疗法对不同亚型患者有效，所以急需新型预测和预后标志物来提高癌症患者的疗效。”miRNAs作为细胞通路的重要调控因子，在癌变过程中起着关键作用。最近研究已鉴定出许多潜在癌症标志物的miRNAs，部分miRNAs起癌基因、抑癌基因或转移调节因子的作用。因为不同癌症疗法对不同亚型患者有效，所以急需新型预测和预后标志物来提高癌症患者的疗效。

吸烟与非吸烟非小细胞肺癌患者的癌症研究 美国癌症研究学会(AACR)2009年会快报

第100届AACR年会于2009年4月18日-22日在美国丹佛市举行,17000多名从事癌症基础研究、转化研究和临床研究的人员参加了此次会议,在此对人们感兴趣的众多领域的最新进展进行了交流和探讨。会议报道了肿瘤学和相关医学科学的最新研究动态。其中涵盖一系列不同议题,包括从基础研究到某些癌症目前未知的发病机理和机制的探索。作为肺癌最常见的类型,非小细胞肺癌(NSCLC)的相关报告是本次会议的重要组成部分。一些研究开始关注于有或无吸烟史的NSCLC患者的分子生物学方面。而且,治疗NSCLC的现有和在研药物疗效的研究结果也是会议重要议题。本会议报告旨在为读者提供2009年AACR年会上关于吸烟与非吸烟NSCLC患者研究成果的概述。

miRNAs在肺癌中的作用

＂这些miRNAs在血清中的高表达是非小细胞肺癌的血液生物标记物……＂ 肺癌居全球癌症死亡原因的首位,但迄今尚无有效针对这一致命疾患的诊断和预测性生物标记物。新证据表明,miRNAs具有以细胞周期依赖性方式调节转录及翻译的潜能，这为我们在分子水平深入理解癌症开拓了新视野。

癌症研究进展：第100届AACR年会见闻

本文将综述2009年美国癌症研究学会(AACR)第100届年会的主要报告,并讨论各项科研成果,以及它们对临床实践和在研临床试验的影响。在这些报告中,靶向治疗的预测性生物标记物的相关报道让适当患者选择合适药物变得可行。通过对体细胞基因拷贝数改变、基因组重排及序列突变进行分析,癌基因组的研究结果在深入揭示多种癌症的发病机制中显示了重要作用。有报告再次证实癌干细胞在治疗性抵抗、促血管生成和转移中起重要作用。有报告从不同角度对各种癌症类型中癌干细胞生物学的认识作了介绍。有报告对小分子RNA(microRNA)改变的最新研究成果进行了概述。除癌细胞研究外,研究人员已开始观察肿瘤细胞与其周围环境的信息交流。有报告介绍了肿瘤微环境与炎症方面的最新成果。有报告陈述了纳米技术和生物标记物发现的最新进展。此外,大会上有些临床试验结果支持应用新的靶向治疗方法,而有些研究者则致力于采用现有药物和方法进行癌症预防。本文将对2009年AACR年会的上述及其它重要报告进行讨论,旨在为读者提供全球最重要癌症研究会议上的癌症研究最新进展。

蛋白质组学与转化医学：用以癌症诊断、预后和疗效预测的分子生物标记物

“生物医学研究的最新技术进展使鉴定多种分子生物标记物变得更加容易，有助于促进癌症筛查和检测……通过允许医生为患者制定个体化治疗来提高癌症治疗的有效性和安全性。”

MiRNA作为肺癌分子诊断工具的前景与挑战

“在过去的十年里，miRNA已成为调节基因表达的关键分子之一。它几乎涉及肺癌癌变的每一个进程，包括肿瘤进展、血管新生、侵袭和转移。”