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Background Malawi has a rising burden of musculoskeletal trauma, coupled with insufficient surgical capacity to manage common, debilitating injuries like femoral shaft fractures. Nonoperative treatment remains the standard of care, with surgery available only at central hospitals. We sought to understand how patients navigate the Malawian health system and the barriers they face while seeking care. Methods We performed in-depth, semistructured interviews of 15 adults with closed femoral shaft fractures during their hospitalization at Kamuzu Central Hospital, a public referral hospital in Lilongwe--Malawi's capital city. We additionally interviewed 1 patient who left Kamuzu Central Hospital to seek care at a private hospital. An English-speaking investigator performed all interviews with a Chichewa-speaking medical interpreter. Interviews focused on patients' pathways from injury to present treatment (health system navigation), impressions of the hospital and care received, and the effects of injury and treatment on patients and their families. Interviews were audio recorded, translated, and transcribed in English. We coded the transcripts and performed thematic analysis. Results We identified 6 themes: high variability in health system navigation; frustrations with the biopsychosocial effects of hospitalization; lack of participation in decision-making and uncertainty about treatment course; preference for surgery (vs traction) based on patients' experiences and observations; frustrations with the inequitable provision of surgery; and patients' resignation, acceptance, and resilience in the face of hardship. Many patients receiving nonoperative treatment described the devastating financial burden imposed upon them and their families by their injuries and prolonged hospitalization. These patients viewed nonoperative treatment as inferior to surgery and suspected that richer patients were receiving more timely care. Conclusions This qualitative study suggested a need to standardize care for femoral shaft fractures in Malawi, increase the availability and timeliness of surgery, and increase transparency and communication between providers and patients. These remedies should focus on improving the quality of care and achieving equity in access to care. [ABSTRACT FROM AUTHOR]

Background and purpose — In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST. Patients and methods — This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty. Results — Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66–0.76) and 0.77 (CI 0.71–0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer's perspective, or $1,035 from the societal perspective. Interpretation — IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources. [ABSTRACT FROM AUTHOR]

Background Diagnostics are foundational to effective health systems but remain widely unavailable worldwide, especially in low-income countries like Malawi. To achieve health equity in Malawi, it is necessary to assess the availability of essential diagnostics. Methods We analysed data collected during a nationwide survey of musculoskeletal trauma care capacity. We analysed the presence, availability, and reasons for unavailability of laboratory testing, vital signs monitoring, electrocardiography, and diagnostic radiology at all 25 district hospitals and 4 central hospitals in Malawi. We used geospatial models to estimate the proportion of the Malawian population with 1-hour and 2-hour access to these resources. Taking 1-hour access to most accurately represent geospatial coverage in the Malawian context, a hypothetical intervention was designed whereby diagnostic capacity improvement would be prioritized at selected hospitals to cover at least 75% of Malawians nationwide. Results Twelve of 29 hospitals had basic laboratory testing available when needed, covering an estimated 58% of Malawians with 1-hour access and 95% with 2-hour access. Vital signs monitoring was available when needed at 18 hospitals, covering an estimated 74% of Malawians with 1-hour access and 97% with 2-hour access. Six hospitals reported that electrocardiography was available when needed, covering an estimated 49% of Malawians with 1-hour access and 91% with 2-hour access. Four hospitals had x-ray capacity of adequate quality to make accurate diagnoses when needed, covering an estimated 39% of Malawians with 1-hour access and 86% with 2-hour access. Broken machinery, inadequate supplies, and inadequate staff training were common reasons for resource unavailability. Conclusions Essential diagnostics were found to be unavailable for many Malawians. By prioritizing capacity improvements for all 4 central hospitals and 11 district hospitals, over three-quarters of Malawians could have 1-hour access to laboratory testing, vital signs monitoring, electrocardiography, and diagnostic x-ray. These capacity improvements are essential to meet the needs of a growing population, especially in the context of the current COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background Congenital pseudarthrosis of the tibia (CPT) is a rare condition. The natural history of CPT includes persistent instability and progressive deformity. Several CPT treatment methods have been practiced, however, in Africa where there is scarce information on the modalities of treatment available and their outcomes. Methods A retrospective cross-sectional study which was conducted among patients with CPT at Beit Cure International Hospital (BCIH), Malawi. Forty-four patients were recruited in this study and their treatment modalities and outcomes were analyzed. Results Out of 44 patients recruited in this study, majority (63.6%) were male. The majority of cases were stage 4 congenital tibia pseudarthrosis by Crawford classification. Most patients were treated by more than one surgical modality; however, surgical excision and intramedullary rodding was commonly used (54.7%). The outcomes of treatment were good in 5%, fair in 30%, with amputation in 45% and poor outcomes in 20% of the patients. Complications developed in 60% of patients, predominated by limb length discrepancy. The foot and ankle status were rated by Oxford Foot and Ankle scoring system (OxFAQ). Conclusions Congenital pseudarthrosis of the tibia is a complex congenital disorder with multiple modalities of treatment. Majority of the patients were treated by more than one operation. Some patients ended up with amputation or poor outcome. Limb length discrepancy, deep infection and pin tract infection are among the common complications. [ABSTRACT FROM AUTHOR]

Burkitt lymphoma (BL) is an aggressive B-cell lymphoma that significantly contributes to childhood cancer burden in sub-Saharan Africa. Plasmodium falciparum, which causes malaria, is geographically associated with BL, but the evidence remains insufficient for causal inference. Inference could be strengthened by demonstrating that mendelian genes known to protect against malaria-such as the sickle cell trait variant, HBB-rs334(T)-also protect against BL. We investigated this hypothesis among 800 BL cases and 3845 controls in four East African countries using genome-scan data to detect polymorphisms in 22 genes known to affect malaria risk. We fit generalized linear mixed models to estimate odds ratios (OR) and 95% confidence intervals (95% CI), controlling for age, sex, country, and ancestry. The ORs of the loci with BL and P. falciparum infection among controls were correlated (Spearman's ρ = 0.37, p = .039). HBB-rs334(T) was associated with lower P. falciparum infection risk among controls (OR = 0.752, 95% CI 0.628-0.9; p = .00189) and BL risk (OR = 0.687, 95% CI 0.533-0.885; p = .0037). ABO-rs8176703(T) was associated with decreased risk of BL (OR = 0.591, 95% CI 0.379-0.992; p = .00271), but not of P. falciparum infection. Our results increase support for the etiological correlation between P. falciparum and BL risk., (© 2023 Wiley Periodicals LLC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

In high-income countries, mosaic chromosomal alterations in peripheral blood leukocytes are associated with an elevated risk of adverse health outcomes, including hematologic malignancies. We investigate mosaic chromosomal alterations in sub-Saharan Africa among 931 children with Burkitt lymphoma, an aggressive lymphoma commonly characterized by immunoglobulin-MYC chromosomal rearrangements, 3822 Burkitt lymphoma-free children, and 674 cancer-free men from Ghana. We find autosomal and X chromosome mosaic chromosomal alterations in 3.4% and 1.7% of Burkitt lymphoma-free children, and 8.4% and 3.7% of children with Burkitt lymphoma (P-values = 5.7×10 -11 and 3.74×10 -2 , respectively). Autosomal mosaic chromosomal alterations are detected in 14.0% of Ghanaian men and increase with age. Mosaic chromosomal alterations in Burkitt lymphoma cases include gains on chromosomes 1q and 8, the latter spanning MYC, while mosaic chromosomal alterations in Burkitt lymphoma-free children include copy-neutral loss of heterozygosity on chromosomes 10, 14, and 16. Our results highlight mosaic chromosomal alterations in sub-Saharan African populations as a promising area of research., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Interferon lambda 4 (IFN-λ4) is a novel type-III interferon that can be expressed only by carriers of the genetic variant rs368234815-dG within the first exon of the IFNL4 gene. Genetic inability to produce IFN-λ4 (in carriers of the rs368234815-TT/TT genotype) has been associated with improved clearance of hepatitis C virus (HCV) infection. The IFN-λ4-expressing rs368234815-dG allele ( IFNL4 -dG) is most common (up to 78%) in West sub-Saharan Africa (SSA), compared to 35% of Europeans and 5% of individuals from East Asia. The negative selection of IFNL4 -dG outside Africa suggests that its retention in African populations could provide survival benefits, most likely in children. To explore this hypothesis, we conducted a comprehensive association analysis between IFNL4 genotypes and the risk of childhood Burkitt lymphoma (BL), a lethal infection-associated cancer most common in SSA. We used genetic, epidemiologic, and clinical data for 4,038 children from the Epidemiology of Burkitt Lymphoma in East African Children and Minors (EMBLEM) and the Malawi Infections and Childhood Cancer case-control studies. Generalized linear mixed models fit with the logit link controlling for age, sex, country, P. falciparum infection status, population stratification, and relatedness found no significant association between BL risk and 3 coding genetic variants within IFNL4 (rs368234815, rs117648444, and rs142981501) and their combinations. Because BL occurs in children 6-9 years of age who survived early childhood infections, our results suggest that additional studies should explore the associations of IFNL4 -dG allele in younger children. This comprehensive study represents an important baseline in defining the health effects of IFN-λ4 in African populations.

Background: There is much scope to empower district hospital (DH) surgical teams in low- and middle-income countries to undertake a wider range and a larger number of surgical procedures so as to make surgery more accessible to rural populations and decrease the number of unnecessary referrals to central hospitals (CHs). For surgical team mentoring in the form of field visits to be undertaken as a routine activity, it needs to be embedded in the local context. This paper explores the complex dimensions of implementing surgical team mentoring in Malawi by identifying stakeholder-sourced scenarios that fit with, among others, national policy and regulations, incentives to perform surgery, career opportunities, competing priorities, alternatives for performing surgery locally and the proximity and role of referral hospitals., Methods: A mixed methods approach was used which combined stakeholder input - obtained through two group model building (GMB) workshops and further consultations with local stakeholders and SURG-Africa project staff - and dynamic modeling to explore policy options for sustaining and rolling out surgical team mentoring. Sensitivity analyses were also performed., Results: Each of the two GMB workshops resulted in a causal loop diagram (CLD) with an array of factors and feedback loops describing the complexity of surgical team mentoring. Six implementation scenarios were defined to perform such mentoring. For each the resource requirements were identified for the institutions involved - notably DHs, CHs and the party that would finance the required mentoring trips - along with the potential for scaling up surgery at DHs under severe financial constraints., Conclusion: To sustain surgical mentoring, it is important that an approach of continued communication, monitoring, and (re-)evaluation is taken. In addition, an output- or performance-based financing scheme for DHs is required to incentivize them to scale up surgery., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

In this observational study, we describe the medium-term outcomes of total joint arthroplasty (TJA) in human immunodeficiency virus (HIV)-positive patients in Malawi, a low-income country. With a high prevalence of HIV and increasing arthroplasty rates in low and middle-income countries, understanding the outcomes of TJA in this unique cohort of patients is essential to ensure that surgical practice is evidence-based., Methods: Data for all HIV-positive patients who had TJA from January 2005 to March 2020 were extracted from the National Arthroplasty Registry of the Malawi Orthopaedic Association (NARMOA). From January 2005 to March 2020, a total of 102 total hip arthroplasties (THAs) and 20 total knee arthroplasties (TKAs) were performed in 97 patients who were HIV-positive and without hemophilia or a history of intravenous drug use. The mean length of follow-up was 4 years and 3 months (range, 6 weeks to 15 years) in the THA group and 4 years and 9 months (range, 6 weeks to 12 years) in the TKA group. The mean patient age was 50 years (range, 21 to 76 years) and 64 years (range, 48 to 76 years) at the time of THA and TKA, respectively., Results: The primary indication for THA was osteonecrosis (66 hips). In the THA group, the mean preoperative Oxford Hip Score and Harris hip score were 14.0 (range, 2 to 33) and 29.4 (range, 1 to 64), respectively, and improved to 46.6 (range, 23 to 48) and 85.0 (range, 28 to 91) postoperatively. The primary indication for TKA was osteoarthritis (19 knees). The mean preoperative Oxford Knee Score was 14.9 (range, 6 to 31) and increased to 46.8 (range, 40 to 48) postoperatively. In patients who underwent THA, there was 1 deep infection (1 of 102 procedures), and 6 patients developed aseptic loosening (6 of 102). There was 1 postoperative superficial infection following TKA (1 of 20 procedures), and 1 patient developed aseptic loosening (1 of 20). Postoperative 6-week mortality among all patients was zero., Conclusions: To our knowledge this is the largest medium-term follow-up of HIV-positive patients, without hemophilia or a history of intravenous drug use, who have had TJA in a low-income country. This study demonstrated good medium-term results among HIV-positive patients undergoing TJA, low complication rates, and improvements in patient-reported outcome measures., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A339)., (Copyright © 2021 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

We describe our 10-year experience performing total hip arthroplasty (THA) in patients enrolled in the National Joint Registry of the Malawi Orthopaedic Association., Methods: Eighty-three THAs were performed in 70 patients (40 male and 30 female) with a mean age of 52 years (range, 18 to 77 years). The cohort included 24 patients (14 male and 10 female; mean age, 52 years [range, 35 to 78 years]) who were human immunodeficiency virus (HIV)-positive., Results: The main indications for surgery were osteonecrosis (n = 41 hips) and osteoarthritis (n = 26 hips). There were no deaths perioperatively and no early complications at 6 weeks. Forty-six patients (59 THAs) were seen at 10 years postoperatively, with a mean Harris hip score (HHS) of 88 (range, 41 to 91) and a mean Oxford Hip Score (OHS) of 46 (range, 25 to 48). Five hips (8% of 59) were revised due to loosening (n = 4) and fracture (n = 1). There were no infections or dislocations. Fourteen patients died, including 4 HIV-positive patients, of unknown causes in the follow-up period, and 10 patients were lost to follow-up. In the group of 24 HIV-positive patients, there were no early complications, and the mean HHS was 88 (range, 76 to 91) at >10 years., Conclusions: Our 10-year experience and long-term outcomes after primary THA in a low-income setting show that good results can be achieved within a controlled hospital environment, thereby establishing a benchmark against which other hospitals and registries in similar low-income countries can compare their results., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2019 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: We describe our 10-year experience with total knee arthroplasty in patients who are included in the Malawi National Joint Registry., Methods: A total of 127 patients underwent 153 total knee arthroplasties (TKAs) between 2005 and 2015. The mean duration of follow-up was 4 years and 3 months (range, 6 months to 10 years and 6 months). The study group included 98 women and 29 men with a mean age of 65.3 years (range, 24 to 84 years). Nine patients were human immunodeficiency virus (HIV)-positive., Results: The primary indication for surgery was osteoarthritis (150 knees), and the mean preoperative and postoperative Oxford Knee Scores were 16.81 (range, 4 to 36) and 45.61 (range, 29 to 48), respectively. Four knees (2.6%) were revised because of early periprosthetic joint infection (1 knee), aseptic loosening (1 knee), and late periprosthetic joint infection (2 knees). There were no perioperative deaths. In the group of 9 patients who were HIV-positive, there were no early or late complications and the mean Oxford Knee Score was 47 (range, 42 to 48) at the time of the latest follow-up., Conclusions: This study demonstrated good short-term results following 153 primary TKAs performed in a low-income country., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

We present a case series of 5 patients admitted over 5 months to Queen Elizabeth Central Hospital who had sustained injuries from a crocodile bite. Three patients required amputation of a limb. The severe soft tissue injury associated with a crocodile bite and the unusual normal oral flora of the crocodile create challenges in treatment. Progressive tissue destruction and haemolysis are complications of such infected wounds. An antibiotic regime is recommended that covers gram negative rods, anaerobes and may include doxycycline, as well as the need to have a low threshold for early amputation.