Malawi Medical Journal 2022-04-13T10:03:38+00:00 Prof. Adamson S. Muula Open Journal Systems The <em>Malawi Medical Journal </em>is a peer reviewed publication of scientific medical research and serves as a forum for the dissemination of findings of health-related research undertaken in Malawi to health workers in Malawi. It incorporates original research studies, policy analysis, case reports, literature reviews and occasional special features. It is published both in print and electronically on a quarterly basis. <br /><br /><p>Other websites related to this journal: <a title="" href="" target="_blank"></a></p> The role of a medical doctor in war-thoughts over Russian soldiers and Ukraine 2022-04-06T12:03:15+00:00 Adamson Muula <p>In 1992, I interviewed for both medical school and the Malawi Army to join my country’s medical corps in preparation for a military hospital that was soon to be established. From that time many things changed. Although I graduated from medical school, I did not become a military doctor. I have <br>fond images of what it would have been, had my dreams of joining the uniformed forces of my country come to fruition.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 Antibiotic guideline adherence by Clinicians in medical wards at Queen Elizabeth Central Hospital (QECH), Blantyre Malawi 2022-04-08T14:59:11+00:00 Grace Thandekire Sibande Ndaziona Peter Kwanjo Banda Thandizo Moya Sylivia Siwinda Rebecca Lester <p><strong>Background</strong><br>Antimicrobial resistance (AMR) is a major concern in health care worldwide. In Malawi rates of AMR, in particular third-generation cephalosporin-resistant (3GC-R) Enterobacterales have rapidly increased since 2003. Antibiotic guidelines are a key component of antimicrobial stewardship (AMS). As part of stewardship, Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi developed an antibiotic guideline in the form of a smart phone application in June 2016.<br><strong>Aim</strong><br>We conducted a study to assess clinicians adherence to the local antibiotic guideline on the adult medical wards, two years after it was introduced. Specifically assessing choice of antibiotic, time of blood culture collection and 48-hour review.<br><strong>Methods</strong> <br>A cross-sectional study was carried out using purposive sampling method. 230 case files of adult patients were audited against the antibiotic guideline. Adherence to the guideline in terms of indication for antibiotic, choice of antibiotic and antibiotic review time was reviewed. Statistical analysis was done using IBM SPSS and presented with descriptive statistics.<br><strong>Results</strong><br>194 (84% [95% CI 79.0-88.8]) antibiotic prescriptions were adherent to the guideline, 28 (12% [95% CI 8.2-17.1]) non-adherent and 8 (3.5% [95% CI 1.5-6.7]) antibiotic indication was not clear. The most common indication for antibiotic prescriptions was pneumonia, as documented in 89 (39% [95 % CI 32.4-45.3]) case files. 191(76% [95% CI 70.3-81.2]) of prescriptions were for ceftriaxone. There was evidence of utilising blood culture to adjust therapy as 88/230 (38% [95% CI 32.0-44.9]) had culture taken. 175(76% [95 % CI 70.0-81.4]) of files had antibiotics reviewed within 48 hours.<br><strong>Conclusion</strong> <br>There is still need to work on rational prescribing of antibiotics as ceftriaxone usage was high during this study period. Scheduled audits and point prevalence surveys should be implemented quickly to reduce the impact of antibiotic resistance and improve individual patient care.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ Antimicrobial susceptibility profiles of clinically important bacterial pathogens at the Kamuzu Central Hospital in Lilongwe, Malawi 2022-04-06T14:21:35+00:00 Faheema E Choonara Bjørg C. Haldorsen Isaac Ndhlovu Osborne Saulosi Tarsizio Maida Fanuel Lampiao Gunnar S. Simonsen Sabiha Y. Essack Arnfinn Sundsfjord <p><strong>Background</strong><br>The aim of this prospective study was to ascertain antimicrobial resistance (AMR) in clinical bacterial pathogens from in-hospital adult patients at a tertiary hospital in Lilongwe, Malawi.<br><strong>Methods</strong> <br>Clinical specimens (blood culture, pus, urine and cerebrospinal fluid) collected during June to December 2017 were examined for bacterial growth in standard aerobic conditions. One specimen per patient was included. Antimicrobial susceptibility testing (AST) was performed using the disk diffusion method and interpreted according to EUCAST guidelines. <br><strong>Results</strong><br>A total of 694 specimens were collected during the study period, of which 336 (48%) specimen yielded visible bacterial growth. Of the 336 specimens, a total of 411 phenotypically different isolates were recovered. Of the 411 isolates, 84 isolates (20%) were excluded and the remaining 327 (80%) were further characterised. The characterised isolates were identified as ESKAPE pathogens (n=195/327; 60%), <em>Escherichia coli</em> (n=92/327; 28%), <em>Proteus mirabilis</em> (n=33/327; 10) or <em>Salmonella spp</em>. (n=7/327; 2%) and were included for further analysis. The excluded isolates (n=84) comprised of coagulase-negative <em>staphylococci</em> (n=25), streptococci (n=33), and low-prevalence Gram-negative bacilli (n=26). <em>E. coli</em> (n=92; 28%) and <em>S. aureus</em> (n=86; 26%) were the most dominant species. A multidrug resistant (MDR) extended spectrum β- lactamase (ESBL)-positive phenotype was detected in Klebsiella pneumoniae (n=20/29; 69%) and <em>E. coli</em> (n=49/92; 53%). One third of the Pseudomonas aeruginosa isolates were resistant to meropenem (MEM), but did not appear to be carbapenemase-producers. Methicillin resistant <em>Staphylococcus aureus</em> (MRSA) was molecularly confirmed in 10.5% of <em>S. aureus</em> (n=9/86). <br><strong>Conclusion</strong> <br>The high proportion of the MDR ESBL-phenotype in clinical isolates of <em>Enterobacterales</em>, strongly limits antimicrobial treatment options and has consequences for empirical and targeted antimicrobial treatment as well as clinical microbiology services and hospital infection control. There is need for a continuous surveillance and an antimicrobial stewardship (AMS) program to contain and prevent the spread of AMR.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ Serum antibodies to selected Helicobacter pylori antigens are associated with active gastritis in patients seen at the University Teaching Hospital in Lusaka, Zambia 2022-04-08T08:36:43+00:00 Violet Kayamba Julia Butt Matthew Gordon Varga Aaron Shibemba Maria Blanca Piazuelo Keith Turker Wilson Kanekwa Zyambo Simutanyi Mwakamui Chola Mulenga Tim Waterboer Meira Epplein Douglas Corbett Heimburger Masharip Atadzhanov Paul Kelly <p><strong>Introduction</strong><br>Little is known about specific bacterial characteristics of Helicobacter pylori (H. pylori) infection influencing gastric carcinogenesis in Zambia. The aim of this study was to evaluate the associations between pre-selected H. pylori antibodies with gastric cancer, premalignant lesions and active gastritis. <br><strong>Methods</strong><br>This was cross-sectional study with multiple comparisons of patients with gastric cancer (GC), gastric premalignant (GP) lesions and active or chronic gastritis. A fluorescent bead-based antibody multiplex serology assay was used to quantify antibodies to thirteen immunogenic <em>H. pylori</em> antigens. Logistic regression models were used to examine the associations.<br><strong>Results</strong><br>Included were 295 patients with: 59 GC, 27 GP lesions, 48 active and 161 chronic gastritis. Overall, 257/295 (87%) were <em>H. pylori </em>positive. <em>H. pylori</em> seropositivity was not associated with sex, age, body mass index, socio-economic status, HIV infection, alcohol consumption or cigarette smoking (p-values all above 0.05). When compared to the patients with chronic gastritis, the presence of catalase and cinnamyl alcohol dehydrogenase (Cad) antibodies was positively associated with GP lesions (OR 3.53; 95% CI 1.52-8.17 and OR 2.47; 95% CI 1.08-5.67 respectively). However, seropositivity to Cad antibodies was significantly lower in GC patients (OR 0.28; 95% CI 0.09-0.83). Compared to chronic, active gastritis was significantly associated with (p&lt;0.05) <em>H. pylori</em> sero-positivity (OR 9.46; 95% CI 1.25-71.52) and specific antibodies including cytotoxin-associated gene A, vacuolating cytotoxin A, <em>Helicobacter cysteine</em>-rich protein C, hypothetical protein HP0305 and outer membrane protein HP1564. <br><strong>Conclusions</strong><br>Among Zambian patients seen at a single center, antibodies to <em>H. pylori</em> (CagA, VacA, Omp, HcpC, HP0305 and HpaA) were associated <br>with active gastritis.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ The beneficial effect of Adansonia digitata products success to modulate lipid profiles and inhibit LDL oxidation in-vitro: An associational study 2022-04-08T14:55:23+00:00 Ahmed M. Ahmed Omar F. Khabour Amjad Yousuf Saber M. Eweda Walaa Mohammedsaeed Haytham M. Daradka Salwa F. M. Hassanein Amna M. Ibrahim <p><strong>Background</strong><br>There is a growing interest in medicinal plants in recent years due to their many therapeutic benefits and low side effects. Among the medicinal plants is the African <em>Adansonia digitata</em> (baobab) that has edible fruit. In the current study, the effect of <em>A. digitata</em> juice consumption on the lipid profile was investigated. In addition, inhibition of the oxidation of low-density lipoprotein cholesterol (LDL-C) in-vitro by <em>A. digitata</em> essential oil (EO) was also investigated. <br><strong>Methods</strong><br>In this cohort study, a total of 70 subjects of <em>A. digitata</em> users (AD group, 42 male and 28 female) and 70 non A. digitata users (Non-AD group, 44 male and 26 female) were recruited to participate in this study. We evaluated lipid profile, HbA1c, liver/kidney functions, and phytosterol contents in fasting blood samples of all participants.<br><strong>Results</strong><br>The present findings illustrated significantly lower levels of total cholesterol, triglycerides, and LDL in the AD group compared to Non-AD (p &lt; 0.01). In addition, essential oil of <em>A. digitata</em> inhibited LDL oxidation in-vitro as shown by the significant decreases in the formation of malonaldehyde (MDA), protein carbonyl (PC), and lipid hydroperoxide (LHP) (P&lt;0.05). No significant changes in fasting blood glucose, HbA1c, HDL, kidney function, and liver function enzymes between the two groups were detected (P&gt;0.05). <br><strong>Conclusion</strong><br>The juice of <em>A. digitata</em> has hypolipidemic and antioxidative effects and might be beneficial for the management of lipid levels in the body.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ Socio-demographic characteristics of children and young adults with varied asthma control- does it make a difference? 2022-04-13T09:26:26+00:00 Eze N Joy Ayuk C Adaeze Ughasoro D Maduka Oguonu Tagbo <p><strong>Background</strong> <br>The socioeconomic status and caregiver perception of asthma as a disease, the availability of specialty care and medication adherence have major influence on outcome of asthma control in children with asthma. The control of asthma therefore depends on the optimizing the interplay of these factors taking into consideration the regional and racial variations.<br><strong>Objective</strong><br>The objective of this study was to evaluate the association between socio-demographic factors and asthma control outcome in children with asthma.<br><strong>Materials and Methods</strong><br>This was a cross-sectional study involving 66 consecutively enrolled participants with asthma whose economic burden for asthma was assessed in a previous study. Based on the number of registered children attending the clinic, a minimum sample size of 66 calculated for this study was obtained.The participants were consenting children and young adults between the ages of 1 and 20 years. Using standard methods, data on socio-economic status, personal and family demographics, including household number, mothers’ educational attainments and employment status; and asthma control were collected and analyzed. Asthma control was assessed using Asthma control test (ACT) and guided by the original developers scoring, participants were grouped into well controlled, partly controlled and uncontrolled. The Chi-square test was used to test for association between participants’ socio-demographic characteristics (age, socioeconomic status, mothers’ education and employment, and number of children in the household) and asthma control status at 5% level of significance. <br><strong>Results</strong><br>Of all study participants, 34 (51.55%) were male, with mean age (SD) of 11.6 (4.8) years. The mean (SD) age at initial asthma diagnosis was 6.2 (4.6) years. The majority 49(76.5%) of the mothers had tertiary education. Study participants belonging to the poorest; very poor; poor; and least poor socio-economic cadres were, 16 (24.2%); 17 (25.8%); 17 (25.8%); and 16 (24.2%) respectively. Asthma control classification showed that, 26 (39.4%); 31 (47%) and 9 (13.6%) participants had well controlled asthma, partially controlled asthma and uncontrolled asthma respectively. The factors like age, socioeconomic status, mothers ‘educational level, employment status and number of children in the household did not show any statistically significant association with the asthma control status of participants.<br><strong>Conclusions</strong> <br>Asthma control outcome remains multifactorial as participants’ socio-demographic characteristics did not impact on the level of control of asthma, among participants in the south eastern parts of Nigeria, despite being in a LMIC. A larger study is recommended <br>to further explore this.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ Factors affecting the failure of High Flow Nasal Cannula Oxygen therapy in Intensive Care follow-up of COVID-19 Severe Respiratory Failure 2022-04-08T11:46:43+00:00 Çiyiltepe Fulya Geçici Mehmet Kahraman Ersin Bilir Yeliz Bombacı Elif Saraçoğlu Kemal <p><strong>Aim</strong><br>Acute respiratory distress syndrome is the primary clinical problem that requires follow-up at the intensive care units. High Flow Nasal Cannula Oxygen Therapy has become an increasingly popular method by reducing the need for intubation but determining which patient will benefit from High Flow Nasal Cannula Oxygen Therapy is an important issue. <br><strong>Methods</strong> <br>Seventy patients who followed up with acute respiratory distress syndrome related COVID-19 treated with High Flow Nasal Cannula Oxygen Systems as initial treatment at the intensive care units were retrospectively review. The primary endpoint of this study is to identify factors correlating with failure (mortality and invasive mechanical ventilator requirement) of High Flow Nasal Cannula Oxygen Therapy in the treatment of COVID-19-related severe ARDS. The secondary aim of this study is to determine the ROX index measured at the 12th hour, which will indicate the need for intubation in critically ill patients followed up with HFNC.<br><strong>Results</strong> <br>Advanced age, male gender, and low ROX index were independent variables affecting High Flow Nasal Cannula Oxygen Therapy failure. While mortality was lowest in patients who completed the process with High Flow Nasal Cannula Oxygen Therapy treatment, patients who were intubated early (12-24h) had lower mortality than those who were intubated later (&gt;24h) (Mortality rates were %4,3 ,%65,6 ,%93,3 respectively). The cut-off value for ROX index, which will indicate the need for intubation, was found to be 2.84. <br><strong>Conclusion</strong><br>High Flow Nasal Cannula Oxygen Therapy can be an effective treatment method in the follow-up of patients with COVID-19-related severe respiratory failure. Despite this, the requirement for intubation develops in two third of the patients. Early intubation reduces mortality in patients who fail High Flow Nasal Cannula Oxygen Therapy, and the easily calculated ROX index is a useful parameter to determine the need for intubation.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ The burden of surgical complications from unsafe abortion treated at the John F. Kennedy Maternity Center (JFKMC), Monrovia, Liberia. 2022-04-08T12:00:11+00:00 Williams O. Odunvbun Jewel T. Kollie <p><strong>Background</strong> <br>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.<br><strong>Method</strong><br>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.<br><strong>Results</strong><br>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. <br><strong>Conclusion</strong><br>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.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ Systematic assessment of complications after laparoscopic colorectal surgery for advanced colorectal cancer: A retrospective study using Clavien–Dindo classification, 5-year experience 2022-04-08T12:43:26+00:00 Mahmut Said Degerli Alp Omer Canturk Hilmi Bozkurt Alp Omer Canturk Alp Omer Canturk Orcun Alpay Muzaffer Akinci Yusuf Emre Altundal Turgay Yildiz Dogan Yildirim <p><strong>Aim</strong><br>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.<br><strong>Methods</strong><br>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.<br><strong>Results</strong><br>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&lt;0.001 for all). In addition, positively significantly related to Clavien Dindo classation and tumor diameter in the female sex (p=0.014) detected.<br><strong>Conclusions</strong><br>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.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ Mothers’ breastfeeding attitudes when lactation overlaps with a new pregnancy 2022-04-08T12:59:11+00:00 Nursan Çınar Özge Karakaya Suzan Sümeyra Topal Sultan Pekşen <p><strong>Background and Aim</strong> <br>There is usually a strong cultural taboo when breastfeeding overlaps with pregnancy. A lot of mothers cease breastfeeding their infants when they conceive again due to social pressure, professional advice, or their own beliefs. The present research aimed to reveal the attitudes of mothers who conceived again while breastfeeding their infants and their experiences in this process.<br><strong>Methods</strong><br>The data of the study, were collected between November 2018 and March 2019 in Sakarya University Education and Research Hospital, Sakarya. The study conducted in 40 women in whom lactation overlapped with pregnancy, and the face-to-face interview technique was employed for data collection. Data were collected using an information form containing information about the participants and a semi-structured interview form. The interviews conducted were then examined using the interpretative phenomenological analysis method, one of the qualitative research methods. The codes and themes were created using the NVIVO 9.0 program. In the report of this study, the Consolidated criteria for reporting qualitative research (COREQ) checklist was utilized as a guide.<br><strong>Results</strong><br>The mean age of the mothers is 26.70±4.58 (min: 20, max: 36), 62.5% (n=25) of the mothers were in the third trimester. While 5% of the mothers (n=2) continued breastfeeding during pregnancy, 95% (n=38) ceased breastfeeding at certain periods of pregnancy. It was observed that the mothers who conceived again during the lactation period considerably hesitated how to act about breastfeeding, they were significantly influenced by the people in their environment concerning how to overcome this, and they were often misguided.<br><strong>Conclusion</strong> <br>There is obviously an urgent need for evidence-based studies on the subject. Studies to be carried out in this regard will increase the self-confidence of healthcare professionals and will enable them to perform effective training and counseling on the subject</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ A Malawian pharmaceutical response to the COVID-19 Pandemic 2022-04-08T13:40:26+00:00 Baxter Kachingwe Peter Kumpalume Felix Khuluza Kumbukani Nyirenda Ernest Matambo John Mponda Nettie Dzabala Francis Chiumia Ibrahim Chikowe Frider Chimimba Nelson Nyoloka Louisa Alfazema Happy Nyirongo Dallas Smith <p>The COVID-19 pandemic has elicited swift and innovative responses due to the severity of the outbreak. Higher education institutions worldwide with pharmacy programs have identified vital gaps in COVID-19 care and has undertaken proactive steps to aid in the fight against the coronavirus. In Malawi, the Kamuzu University of Health Science’s Department of Pharmacy initiated the production of a modified formulation of the World Health Organization’s (WHO) recommended hand sanitizer. This manufacturing venture involved mobilizing the pharmacy faculty, identifying gaps in supplies and equipment, and utilizing evidenced-based information to create a high-quality sanitation product, which passed the requirements as tested by the Malawi Bureau of Standards. The department of pharmacy is expanding their distribution of the product to meet the needs of frontline healthcare workers and vulnerable populations. <br>With historical issues of accessing care in Malawi and with COVID-19’s spread among healthcare workers, this hand sanitizer venture is vital in the public healthcare’s system response. The department of pharmacy will continue to lead the pharmacy profession in Malawi to provide targeted interventions in this unprecedented time.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ A rare lesıon of breast: Hydatıd cyst 2022-04-13T09:58:38+00:00 Sinan Sozutok Omer Kaya Huseyin Akkaya Bozkurt Gulek <p>Hydatid cyst (HC) is a lesion most commonly seen in the liver but can occur in many parts of the body. Breast involvement with HC&nbsp; is extremely rare. It can be isolated or accompanied by other organ involvements. In this report, we present a 46-year-old female with&nbsp; isolated HC located in the right breast. In the ultrasonography and MR images of the patient, the lesion was compatible with the HC,&nbsp; and homogenous dens lesion was shown on mammography. Diagnosis of HC was confirmed pathological. With this study, it was aimed to emphasize the radiological findings of isolated breast HC.</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ Pharmacists’ Readiness to Receive, Recommend and Administer COVID-19” Vaccines 2022-04-08T14:13:27+00:00 Rujittika Mungmunpuntipantip Viroj Wiwanitkit <p>We would like to share ideas on “Pharmacists’ Readiness to Receive, Recommend and Administer COVID-19 Vaccines in an African Country: An Online Multiple-Practice Settings Survey in Nigeria.” Isah and Ubaka proposed that “most pharmacists are willing to accept to be vaccinated against COVID-19….</p> 2022-04-01T00:00:00+00:00 Copyright (c) 2022 MMJ