Malawi Medical Journal

Thoughts about the 2023/4 Malawi National Health Budget

Adamson S. Muula — 2024-07-14

At 12% of the total national budget, the proposed 2024/24 health budget is most likely the highest ever in Malawi. I say “most likely” or probably, because I have not been careful enough to review what was the country’s health budget in the 1960’s, 80’s, or the 90’s. In addition, in the Malawi context, the budget as approved by the National Assembly and assented to by the State President, doesn’t always mean that it will be followed to the letter through treasury disbursements to Ministries, Departments and Agencies (MDAs). But 12% isn’t lower when one looks at the other sectors (defence, homeland security, foreign affairs, education and agriculture) which the same national fiscus seeks their attention.

Building a complementary approach to HIV service delivery for key populations using health facilities in collaboration with community-based organizations in Liberia

Gift Kamanga — 2024-07-14

Key populations (KPs), including female sex workers (FSWs), men who have sex with men (MSM), transgender (trans) people, prisoners, and people who use drugs, have specific risk behaviours and other vulnerabilities that place them at increased risk of HIV1. In addition, they play an important role in the dynamics of HIV prevention and transmission both within and outside of KP communities, as KPs and the general population are frequently interconnected through their sexual networks.

Clinico-epidemiological profile of skin cancer in South Western Nigeria

Vitalis Chukwuemeka Okwor — 2024-07-14

Background
Skin cancer is one of the most common forms of cancer. The incidence of skin cancer is on the increase among Caucasians and Africans, though there are significant differences in the pattern of presentation. This study sought to evaluate the pattern of skin cancer presentation in Ibadan, south-west Nigeria. The objective of the study was to determine the risk factors and pattern of presentation.
Methods
Data extraction forms were used to obtain information from the hospital records of patients with histological diagnoses of skin cancer between January 2001 and December 2010. The study took place at the Radiation Oncology Department, University College Hospital, Ibadan, Nigeria.
Results
A total of 126 cases were identified. The age range of patients was from 7 to 98 years, with a mean age of 46.6 years. The male-to-female ratio was 1.5:1. The peak age of incidence was between 40 and 49 years old. Of the risk factors, trauma (18.3%) and albinism (15.9%) were the most common. Squamous cell carcinoma (63%) was the most common histological sub-type recorded. The majority of the respondents presented with locally advanced (43.7%) and metastatic (22.2%) stages. The lower limb (59.9%) and head and neck region (22.0%) were the most commonly affected sites. The lungs (46.4%) were the most common site of distant metastases, followed by the liver (21.4%), and the brain (7.1%) was the least common site of metastasis.
Conclusion
The finding that majority of the respondents in this study presented with locally advanced and metastatic disease buttresses the need for public awareness programs to ensure uptake of preventive measures by the populace and emphasizes the need for early presentation.

Trends in severe acute malnutrition admissions, characteristics, and treatment outcomes in Malawi from 2011 through 2019

Allison I. Daniel — 2024-07-14

Background
Community-based Management of Acute Malnutrition (CMAM) has been successfully implemented across Malawi, yet trends in admissions, characteristics, and treatment outcomes in children with severe acute malnutrition (SAM) have not been examined. The objective was therefore to investigate trends in admissions, characteristics including percentage of children with SAM with HIV and oedema, and treatment outcomes across the decade following implementation of CMAM.
Methods
This research involved a retrospective analysis of existing data routinely collected across Malawi by the Ministry of Health between 2011 and 2019.
Results
These data showed an increase in outpatient therapeutic feeding (OTP) admissions from 30323 children in 2011 to 37655 in 2019 (p=0.045). However, a significant decrease in nutritional rehabilitation unit (NRU) admissions was observed, from 11389 annual admissions in 2011 to 6271 in 2019 (p=0.006). In children identified with SAM, the percentage with oedema decreased in OTPs with an average annual rate of reduction (AARR) of 5.6% (p=0.001) and by 26.2% in NRUs in this timeframe with an AARR of 8.5% (p<0.001). The percentage of children with SAM who had HIV decreased over time in OTPs with an AARR of 16.1% (p=0.001). HIV rates also decreased in NRUs with an AARR of 7.2% (p=0.4), but this difference was not significant. Death rates decreased in OTPs with an AARR of 6.0% (p=0.01). Mortality rates did not change in NRUs over time with an AARR of 0.9% (p=0.5) with the NRU mortality rate in 2019 being 11.0%.
Conclusions
These trends indicate that there has been an increase in OTP admissions and a corresponding decrease in NRU admissions. There have been decreases in the percentage of children with oedematous SAM in OTPs and in NRUs and with HIV in OTPs. Children remain at high risk of mortality in NRUs.

Mental health and sleep quality: are intuitive eating, hedonic hunger and diet quality, determinants? a cross-sectional study

Kevser Sare Ateş — 2024-06-30

Background
Intuitive eating may predict better psychological and behavioral health. Intuitive eating, hedonic hunger, and diet quality may affect
individuals’ mental health and sleep quality.
Methods
Descriptive cross-sectional study developed with an online questionnaire for randomly selected volunteers (n=351) aged 19-64 years.
Hedonic hunger status was evaluated by Power of Food Scale (PFS), intuitive eating by Intuitive Eating Scale-2 (IES-2), mental health
status by Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) and sleep quality by Pittsburgh Sleep Quality Index (PSQI). Food
consumption records were taken to evaluate individuals’ dietary quality, using Healthy Eating Index (HEI)-2015.
Results
It was found that 50.7% of the participants exhibited intuitive eating behavior, while 65.0% experienced hedonic hunger. When the diet quality was examined, it was found that 65.2% of the participants had poor diet quality, while 33.6% needed to improve their
diet quality. Sleep quality and mental health status of individuals exhibiting intuitive eating behavior were significantly better (p<0.05).
Diet quality was not associated with mental health, intuitive eating, hedonic hunger and sleep quality scores (p>0.05). While there
was a weak negative correlation between intuitive eating and PSQI score (r=-0.160, p<0.05), while a positive correlation was found
between hedonic hunger and PSQI score (r=0.286, p<0.05). Intuitive eating was associated with better sleep quality, as lower PSQI
scores indicate better sleep quality. Intuitive eating was also associated with better mental health (r=0.339, p<0.05).
Conclusion
This study reveals that intuitive eating behavior is associated with better sleep quality and mental health, while hedonic hunger
behavior is associated with poor sleep quality.

Correlation between inferior vena cava collability index and malnutrition in critical patients: a prospective observational study

Veysel G SOYLU — 2024-07-14

Background
We aimed to investigate the correlation between the inferior vena cava collability index(IVC-CI) used in the evaluation of fluid volume and the Nutrition Risk Index(NRI), Prognostic Nutrition Index(PNI), Geriatric Nutrition Risk Index(GNRI) and Controlling Nutritional Status Scoring(CONUT) used in the evaluation of malnutrition.
Methods
This study is a prospective observational study. Demographic data, laboratory data, Body Max Indexes(BMI), NRI, PNI, GNRI and CONUT in the first 24 hours of admission to the intensive care unit of 96 critically ill patients admitted to the tertiary intensive care unit with assisted invasive mechanical ventilator support and IVC-CI values were recorded. Patients with an IVC-CI >45% were evaluated as hypovolemia. Of the patients, 61 (63.5%) patients with an IVC-CI value of 45%≥ were group 1, and 35 (36.5%) patients with an IVC-CI value of >45% were determined as group 2. Correlation between the IVC-CI and malnutrition scores was investigated between the groups.
Results
As a result of the statistical analysis; there was a statistically significant difference between the two groups in terms of BMI, NRI, PNI, GNRI and CONUT (p<0.001). According to the correlation analysis results, NRI (rs=-0.716, p<0.001), PNI (rs=-0.743, p<0.001), GNRI (rs=-0.723, p<0.001), CONUT (rs=0.741, p<0.001) were significantly correlated with the IVC-CI.
Conclusions
This study shows that there is a correlation between the IVC-CI used in the evaluation of fluid volume and malnutrition.

Health-related quality of life and its predictors among hypertensive adults 45 years and older in rural Malawi: a population-based study

Susan Banda — 2024-07-14

Background
Hypertension is associated with impaired Health-Related Quality of Life (HRQOL), but its assessment is rarely done in the
management of hypertension in Malawi. This study aimed to evaluate the HRQOL of hypertensive adults compared to normotensive
individuals and suggest possible predictors of HRQOL in hypertensive adults in rural Malawi.
Methods
This was a cross-sectional study utilizing data from the 2017 Mature Adults Cohort of the Malawi Longitudinal Study for Families
and Health (MLSFH-MAC). The study included 1489 adults aged 45 and above from Rumphi, Mchinji, and Balaka districts. HRQOL
was measured using the Short Form 12-item (SF-12) questionnaire. Univariable logistic regression, followed by multivariable logistic
regression, was used to identify independent predictors of HRQOL in hypertensive adults. A p-value of <0.05 was considered
statistically significant.
Results
The prevalence of hypertension was 44.1%. Hypertensive participants had significantly lower physical and mental HRQOL than their
normotensive counterparts (p<0.05). Multiple regression analysis showed that female sex, age, presence of comorbidities, and use of
antihypertensive medications were significant predictors of poor physical HRQOL. Being female was a significant predictor of poor
mental HRQOL (all p-values <0.05).
Conclusion
In rural Malawi, hypertensive adults presented with lower physical and mental HRQOL. Interventions aimed at improving HRQOL
should focus on hypertensive adults who are female, older, on antihypertensive medications, and with comorbidities.

The effect of COVID-19 phobia on employee performance and job satisfaction: a cross-sectional study

Hatice Serap KOÇAK — 2024-07-14

Background
The mass fear of COVID-19, which is called “coronaphobia”, causes many negative effects such as increasing unemployment rates,
decreased performance in working life and organisational problems in the business world. The study is conducted to examine how
COVID-19 is reflected in job performance and job satisfaction in terms of the sustainability of occupational health and safety of
workers especially white-collar workers, in enterprises due to the pandemic.
Methods
The study was conducted as a descriptive, cross-sectional type. Data were collected from the employees in the designated factories by
creating an online form using the “COVID-19 Phobia Scale”, “Employee Performance Scale”, and “Job Satisfaction Scale”.
Results
The findings obtained in the study showed a significant positive relationship between employee performance and job satisfaction.
It was determined that job satisfaction and employee performance had a significant but weak relationship with COVID-19 phobia.
Conclusions
The findings expand previous studies by filling the lack of knowledge on how job performance and job satisfaction have effected
at workplace during a pandemic. The study data show that job performance and job satisfaction in workplace employees affect each
other and that both are affected by unexpected or extraordinary situations such as pandemics.

Epidemiological, anatomopathological and immunohistochemical profiles of male breast cancer in Sidi Bel Abbes, Algeria (Profiles of male breast cancer)

Zakaria Merad — 2024-07-14

Background
Male breast cancer (BC) is a rare disease, few prospective studies have been undertaken compared to studies carried out in women.
The condition is characterised by unfavorable prognosis when compared to that of females. The aim of the present work is to
describe the anatomopathologic characteristics of males breast cancer at the level of the pathology department of the HospitalUniversity Center of Sidi Bel Abbes (ALGERIA).
Methods
A descriptive cross-sectional study on male breast cancers diagnosed in our pathology department between January 2010 and
December 2020 was undertaken, the variables assessed were epidemiological, macroscopic, microscopic and immunohistochemical
data.
Results
A total of 25 breast male cancer were identified in this study, the mean age at the diagnosis time was 58.8± 3.5 years, and the age was
ranging from 37 to 83. The mean tumor size was 3.58 ± 1.5 cm, with sizeranging from 1.8 to 9 cm. About 18 of patients had tumors
located in the upper outer quadrant (UOQ). Histopathological examination revealed the predominance of invasive carcinoma of
no special type in 22 patients, followed by lobular carcinoma in 2 patients. 18 patients presented with nodal involvement and 23 of
patients had hormonal receptors expression, including oestrogen receptor (RO), and progesterone receptor (RP). Additionnaly, just
one patient had positive overexpression of HER2 (human epidermal growth factor receptor 2).
Conclusion
Breast cancer in males in Algeria appears to be relatively rare and presents at an older age compared to females. Three out of four
patients presented tumors in the UOQ and most were invasive carcinoma no special type. In the majority of male BC cases hormonal
receptors and nodal involvement were present, while HER2 receptors were absent.

Efficacy of HPV E6/E7 mRNA assay, HPV DNA test and cytology in detection of high grade cervical lesions and invasive cancer at a tertiary care center in India

Sangeeta Pankaj — 2024-07-14

Background
Cervical cancer is caused by human papillomavirus (HPV) and remains a major public health issue. There are several methods for its
diagnosis. Knowing their comparative usefulness may help in devising an appropriate strategy for early detection of this gynecological cancer in resource-constrained setting.
Aim
This study aims to evaluate the efficacy of human papillomavirus (HPV) E6/E7 mRNA assay, HPV DNA test and cytology in
detection of high grade cervical lesions and invasive cervical carcinoma at a tertiary care center in India.
Methods
A total of 106 women were recruited in this hospital based study and underwent molecular tests (HPV DNA test and mRNA assay),
cytological test and colposcopic-guided biopsy. Histopathological diagnosis was considered as the gold standard.
Results
We observed that 56 out of 106 participants had abnormal results in the terms of positive HPV DNA or E6/E7 mRNA with or
without abnormal cytology or had histopathologically confirmed pre-malignant/malignant lesion. 47.2% (50/106) and 32% (34/106)
women were positive for HPV DNA and E6/E7 mRNA respectively. 33% (35/106) women had abnormal cytology and 29.2%
(31/106) had histologically confirmed CIN II and higher lesions. Sensitivity and specificity of cytology and HPV DNA for CIN
III+ lesions were calculated as 92%, 90.4% versus 88% & 68% respectively. mRNA assay was found to be more sensitive (96%) and
specific (93.3%) than other tests in detecting CIN II + lesions.
Conclusion
E6/E7 mRNA assay seems superior to HPV DNA test and cytology in detection of high grade cervical lesions and invasive carcinoma.
It may be used as an alternative or adjunct to HPV DNA test or cytology for the purpose of cervical cancer screening and also be
helpful in reducing the load for colposcopy.

Vital Sign alterations within 24 hours prior to death in children with retinopathy-positive Cerebral Malaria at Queen Elizabeth Central Hospital Malawi

Milcent Chintsanya — 2024-07-14

Background
Malaria is a significant obstacle to child health and survival. Plasmodium falciparum infections, especially in children under five, lead to high morbidity and mortality. Cerebral malaria (CM) is a life-threatening complication characterized by coma, and its diagnosis can be improved by observing malarial retinopathy in children. Monitoring vital signs is essential for managing patients with CM.
Objectives
To determine if changes in vital signs predict death in children with retinopathy positive cerebral malaria (RPCM).
Methods
This was a retrospective case-control study using data collected from children admitted to the Paediatric Research Ward at Queen
Elizabeth Central Hospital in Blantyre between 1997 and 2020. Patients who died 24 hours or more after admission were matched
with control patients who survived. Linear regression analyses were used to assess the differential time trends of each vital sign in the
survivor group and death group. Classification models were used to quantify various vital signs’ predictive power of death.
Results
Among the population that died, the estimated change in average respiratory rate per hour approaching death was 0.02 breaths per
minute compared to -0.25 breaths per minute among those who survive (p < 0.001), and the estimated change in average BCS per
hour approaching death was -0.01 compared to 0.06 among the survivors (p < 0.001). Changes in temperature and heart rate were
not associated with clinical deterioration. Three models were developed, and the best receiver operating characteristic curve was 100% sensitive, the corresponding false positive rate was 75%.
Conclusion
Changes in respiratory rate and BCS have prognostic significance in the final 24 hours before death in children with cerebral malaria.
Extra attention should be paid to these two vital signs as they may help to identify children who are at increased risk of deteriorating.

Identifying ribonucleotide reductase subunit genes as potential lung adenocarcinomas biomarkers using integrated bioinformatics analysis

Jin Shang — 2024-07-14

Introduction
Dysregulation of ribonucleotide reductase (RR) subunit genes (RRM1, RRM2 and RRM2B) expression is reported to be involved in the
occurrence of various human malignancies. However, the prognostic value of RR subunit genes expression in lung adenocarcinoma
(LUAD) patients remains controversial.
Objective
This study aims to analyze the expression profiles, prognostic values, and immune infiltrating associations of RR subunit genes in
LUAD to explore whether RR subunit gene expression has value in the prognosis of patients with lung adenocarcinoma (LUAD).
Methodology
We used multiple search engines to access multiple online bioinformatics databases, including Oncomine, TIMER, GEPIA, Kaplan–
Meier Plotter, PrognoScan, the Human Protein Atlas, MD Anderson Cancer Center, UCSC Xena, cBioProtal, TCGA, GEO, DAVID,
and STRING databases.
Results
The study found that RRM1 and RRM2 might be an attractive target for treating LUAD, while RRM2B were down-expressed in LUAD (P < 0.05). The study also found that high RRM1 or RRM2 expression, or low RRM2B expression suggested poor prognosis of LUAD patients in both TCGA and GEO databases (P < 0.05). Additionally, our results indicated that RR subunit genes expressions have different characteristics with immune infiltrating, RRM2B had a slight but significant positive correlation with almost every infiltrating immune cells except CD4+ T cells (all P < 0.05). Furthermore, by co-expression gene network analysis of RR subunit genes, we found that five new hub genes (PLK1, AURKA, CDCA8, TTK and CDC45) were significantly positively correlated with RRM1 and RRM2 expression whereas were negatively correlated with RRM2B expression, and these five hub genes were identified to be related with a poor prognosis in LUAD patients (P < 0.05).
Conclusion
The study findings demonstrate that RR subunit genes may be a prognostic marker and therapeutic target for LUAD patients.

Analyzing 10-year time trends for Hysterectomy and Oophorectomy: Focus on Endometrial sampling and risk factors for Endometrial Cancer

Aslihan Yurtkal — 2024-07-14

Background
Hysterectomy is a versatile and commonly employed treatment option for various benign and malignant gynecological conditions. Our study aims to take a comprehensive perspective on hysterectomy over the years using accumulated data and provide clinicians
with an accurate insight into the hysterectomy operation.
Material-Method
This retrospective observational study was conducted on women who underwent hysterectomy at our clinic between 2012 and 2021. Comprehensive medical histories of all patients were thoroughly reviewed as the primary data. Surgical procedures were categorized and compared by year. Operation indications, preoperative endometrial sampling, and the pathology results of the final hysterectomy specimens were also examined. Risk factors were evaluated in confirmed cases of endometrial cancer and atypic endometrial hyperplasia based on pathology results. The analyses were performed using IBM SPSS 20 statistical analysis software.
Results
In our study,752 patients(mean age: 52±8.2) underwent various hysterectomy procedures, with total abdominal hysterectomy being
the most frequent(73.3%). The primary indication was uterine leiomyomas-adenomyomas(33.5%). Endometrial sampling was
performed in 57.2% of patients, showing no significant difference in reliability(p=0.143) and endometrial cancer diagnosis(p=0.334).
Among 38 patients diagnosed with endometrial cancer, approximately 28.9%(11 patients) did not undergo preoperative endometrial
sampling. Further examination revealed that these patients were obese, 63.6% presented with spotting-like bleeding, and most were
in the postmenopausal period. Risk factors for these patients and those with atypical hyperplasia indicated statistically significant
positive family history(p=0.037) and estrogen therapy history(p=0.028). Out of 536 oophorectomies, 236 were performed in women
under 50.
Conclusion
The study highlights the need to implement the current literature and promote minimally invasive approaches. Widespread adoption
of non-hysterectomy options is essential for rate reduction. Physicians must integrate current literature, refine skills in minimally invasive methods, and advance surgical techniques to achieve an idealized approach for premalignant lesions and endometrial cancer. Presenting clinic data to personalize algorithms and treatments will strengthen the literature, enhancing the field and increasing the applicability of knowledge for personalized implementation of ideal algorithms and treatments.

Pneumatized inferior turbinate (concha bullosa of inferior turbinate)

Anas Elamaireh — 2024-07-14

The nasal cavity structures are prone to different anatomical variations; one of these is concha bullosa, which best known as pneumatization of the nasal turbinate. This pneumatization is a rare phenomenon to in the inferior turbinate. We report the case of an incidental finding of inferior turbinate concha bullosa in a 30- year-old female who presented with nasal obstruction and headache. While evaluating the patient’s computed tomography image, a pneumatized right inferior turbinate accidentally found. Our patient treated medically without surgical intervention and showed good improvement in her symptoms. Physicians should be aware of the presence of such a rare variation that may lead to serious nasal symptoms if it is large enough, they should keep it in the differential diagnosis and with deal with it accordingly.