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Introduction Anemia is a common and potentially modifiable condition in sub-Saharan Africa. We sought to determine the role of preoperative anemia on post laparotomy abdominal complications. Methods We conducted a six-month prospective, observational study of patients age >12 years following laparotomy at a tertiary hospital in Malawi. The outcome was the occurrence of abdominal complications. Poisson regression analyses estimated the risk of abdominal complications in patients with moderate/severe anemia. Results Of 280 patients, most were male (76.4%) with median age of 35 years (IQR 24–50). Abdominal complications developed in 34 patients (15.2%). Of the 224 patients with known preoperative hemoglobin 54 (20.7%) were moderately or severely anemic at the time of surgery. Patients with moderate-to-severe anemia had an increased risk of abdominal complications (RR 4.44, 95% CI 2.0–9.6). Conclusion Anemia is a common but modifiable comorbidity among laparotomy patients and independently increases the risk of abdominal complications.

INTRODUCTION: Despite increases in surgical capacity in Malawi, minimal data exist on post-operative complications. Identifying surgical management gaps and targeting quality improvement requires detailed, longitudinal complications and outcome data that assess surgical safety and efficacy. METHODS: We conducted a six-month prospective, observational study of patients >12 years following laparotomy at a tertiary hospital in Lilongwe, Malawi. Outcomes included post-operative complications and mortality. The senior-most rounding physician determined complication diagnoses. Bivariate and Poisson regression analyses identified predictors of mortality. RESULTS: Only patients undergoing emergent laparotomy (77.8%) died before discharge, so analysis excluded elective cases. Of 189 patients included, the median age was 33.5 (IQR 22–50.5), 22 (12.2%) had prior abdominal surgery, and 11 (12.1%) were HIV-positive. Gastrointestinal perforation was the most common diagnosis (35.5%). The most common procedures were primary gastrointestinal repair (24.9%), diverting ostomy (21.2%), and bowel resection with anastomosis (16.4%). Overall post-operative mortality was 14.8%. Intraabdominal complication occurred in 17 (9.0%) patients, of whom 8 (47.1%) died. Older age (RR 1.05, 95% CI 1.02–1.08, p

INTRODUCTION: The burden of global trauma disproportionately affects low- and middle-income countries, with a high incidence in children. Thermal injury represents one of the most severe forms of trauma and is associated with remarkable morbidity and mortality. The predictors of burn mortality have been well described (age, % total body surface area burn [TBSA], and presence of inhalation injury). However, the contribution of the burn mechanism as a predictor of burn mortality is not well delineated. METHODS: This is a retrospective analysis of prospectively collected data, utilizing the Kamuzu Central Hospital (KCH) Burn Surveillance Registry from May 2011 to August 2019. Pediatric patients (≤12 years) with flame and scald burns were included in the study. Basic demographic variables including sex, age, time to presentation, %TBSA, surgical intervention, burn mechanism, and in-hospital mortality outcome was collected. Bivariate analysis comparing demographic, burn characteristics, surgical intervention, and patient outcomes were performed. Standardized estimates were adjusted using inverse-probability of treatment weights (IPTW) to account for confounding. Following weighting, logistic regression modeling was performed to determine the odds of in-hospital mortality based on burn mechanism. RESULTS: During the study period, 2364 patients presented to KCH for burns and included in the database with 1794 (75.9%) pediatric patients. Of these, 488 (27.6%) and 1280 (72.4%) were injured by flame and scald burns, respectively. Males were 47.2% (n = 230) and 59.2% (n = 755) of the flame and scald burn cohorts, respectively (p < 0.001.) Patients presenting with flame burns compared to scald burns were older (4. 7 ± 3.1 vs. 2.7 ± 2.3 years, p < 0.001) with greater %TBSA burns (17.8 [IQR 10–28] vs 12 [IQR 7–20], p < 0.001). Surgery was performed for 42.2% (n = 206) and 19.9% (n = 140) of the flame and scald burn cohorts, respectively (p < 0.001.) Flame burns had a 2.6x greater odds of in-hospital mortality compared to scald burns (p < 0.001) after controlling for sex, %TBSA, age, time to presentation, and surgical status. CONCLUSION: In this propensity-weighted analysis, we show that burn mechanism, specifically flame burns, resulted in a nearly 3-fold increase in odds of in-hospital mortality compared to scald burns. Our results emphasize flame and scald burns have major differences in the inflammatory response, metabolic profile over time, and outcomes. We may further utilize these differences to develop specialized treatments for each burn mechanism to potentially prevent metabolic dysfunction and improve clinical outcomes.

Background In response to Medicare readmission penalties, some hospitals have introduced transitional care clinics (TCCs) to meet the care needs of patients recently discharged from the emergency room or inpatient setting. This study was undertaken to increase the proportion of low-income, medically complex patients using a TCC at a large academic medical center, Northwestern Medical Group Transitional Care Clinic (NMG-TC). Methods This quality improvement study combined interviews and quantitative data analysis to determine how to increase use of NMG-TC. Physicians and patients were interviewed and surveyed to identify opportunities to expand clinic use. Logistic regression analysis of electronic health record (EHR) data was used to identify sociodemographic and clinical conditions influencing the TCC appointment show rate. Results Provider surveys and interviews suggested that referrals would likely increase via automation of referral guidelines and enhanced transitional care education. Patient interviews indicated that better communication of NMG-TC purpose, emphasizing nonmedical offerings, and warm handoffs could increase engagement. EHR analyses revealed that patients least likely to attend appointments were male, uninsured, non-Hispanic black, or homeless; had documented substance use; or lived > 50 miles from the clinic. Conversely, patients with heart failure, anxiety, or malignancy were more likely to attend appointments. Conclusion TCC show rates could be improved with better communication of NMG-TC benefits to both patients and referring providers, as well as warm appointment handoffs, particularly for patients least likely to attend scheduled visits.

Introduction The burden of critical illness in low- and middle-income countries (LMICs) is high; however, there is a paucity of data describing pediatric critical care outcomes in this setting. Methods We performed a prospective observational study of the pediatric (≤18 years) intensive care population in Malawi, from August 2016 to May 2018. Data collected include patient demographics and clinical data, admission criteria and outcome. A multivariate Poisson regression was performed to determine risk factors for mortality. Results Over the study period, 499 patients were admitted to the intensive care unit (ICU) and 105 (21.0%) were children. The average age was 10.6 ± 5.4 years. Primary indications for ICU admission were sepsis (n = 30, 30.3%) and traumatic brain injury (TBI, n = 23, 23.2%). Of those who died, sepsis (n = 18, 32.7%), acute respiratory failure (n = 11, 20.0%) and TBI (n = 11, 20.0%) were the primary admission diagnoses. Overall, ICU mortality was 54.3% (n = 57). Multivariate regression for increased ICU mortality revealed: age ≤5 years [risk ratio (RR) 1.96, 95% CI 1.10–2.26, p Conclusions Pediatric ICU mortality is high. Predictors of mortality were age ≤5 years, anemia at ICU admission and the need for epinephrine support. Training of pediatric intensive care specialists and increased blood product availability may attenuate the high mortality for critically ill children in Malawi.

Background The presentation of appendicitis in pediatrics is variable, and diagnostic imaging is often used. Magnetic resonance imaging (MRI) is replacing computed tomography in some centers, particularly after a nondiagnostic ultrasound (NDUS). Nonetheless, MRI is not widely used in this setting because of cost, procedure time, institutional capacity, and high rates of negative scans. We hypothesized that the Alvarado Score (AS) could be used to determine the additive diagnostic value of MRI after an NDUS. Materials and methods Retrospective review of patients aged ≤18 y at a single tertiary care children's hospital who received an ultrasound for suspected appendicitis during 10 consecutive months in 2017. NDUS were defined as nonvisualization of the appendix or secondary signs without radiologic diagnosis. AS were retrospectively calculated from the electronic medical record. Primary outcomes were pathology-confirmed appendicitis, appendectomy, and perforation. Results AS was determined for 352 patients out of 463 who met inclusion criteria (76%). Sixty-two percent had an NDUS, and 45% of these patients received MRI. Patients with high-risk AS were significantly more likely to have MRI diagnostic of appendicitis ( P = 0.0015), and low-risk AS patients were more likely to have a negative or equivocal MRI ( P = 0.0169). Twenty-one MRI scans were required per each additional diagnosis of appendicitis in patients with low AS after NDUS versus 4.2 in intermediate-risk AS patients and 2.1 in high-risk AS patients. Conclusions Risk stratification with AS can help assess the additive diagnostic utility of MRI after NDUS. MRI may be overutilized for diagnosing acute appendicitis in pediatric patients with low-risk AS.

Proliferation and differentiation of intestinal epithelial cells (IECs) occur in part through precise regulation of key transcription factors, such as SOX9. MicroRNAs (miRNAs) have emerged as prominent fine-tuners of transcription factor expression and activity. We hypothesized that miRNAs, in part through the regulation of SOX9, may mediate IEC homeostasis. Bioinformatic analyses of the SOX9 3′-UTR revealed highly conserved target sites for nine different miRNAs. Of these, only the miR-30 family members were both robustly and variably expressed across functionally distinct cell types of the murine jejunal epithelium. Inhibition of miR-30 using complementary locked nucleic acids (LNA30bcd) in both human IECs and human colorectal adenocarcinoma-derived Caco-2 cells resulted in significant up-regulation of SOX9 mRNA but, interestingly, significant down-regulation of SOX9 protein. To gain mechanistic insight into this non-intuitive finding, we performed RNA sequencing on LNA30bcd-treated human IECs and found 2440 significantly increased genes and 2651 significantly decreased genes across three time points. The up-regulated genes are highly enriched for both predicted miR-30 targets, as well as genes in the ubiquitin-proteasome pathway. Chemical suppression of the proteasome rescued the effect of LNA30bcd on SOX9 protein levels, indicating that the regulation of SOX9 protein by miR-30 is largely indirect through the proteasome pathway. Inhibition of the miR-30 family led to significantly reduced IEC proliferation and a dramatic increase in markers of enterocyte differentiation. This in-depth analysis of a complex miRNA regulatory program in intestinal epithelial cell models provides novel evidence that the miR-30 family likely plays an important role in IEC homeostasis.