Publications by authors named "Anthony G Charles"

88 Publications

Characteristics and outcomes following motorized and non-motorized vehicular trauma in a resource-limited setting.

Injury 2021 Apr 18. Epub 2021 Apr 18.

Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States. Electronic address:

Introduction: Despite the ubiquity of motorized vehicular transport, non-motorized transportation continues to be common in sub-Saharan Africa.

Methods: We performed a retrospective analysis of trauma patients presenting to Kamuzu Central Hospital in Malawi from February 2008 to May 2018. Demographic and clinical variables including injury characteristics and outcomes were collected. We performed bivariate and multivariate logistic regression to determine predictors of mortality following non-motorized vehicular trauma.

Results: This study included 36,412 patients involved in vehicular road injuries. Patients in the non-motorized group had a preponderance of men (84% versus 73%, p<0.01). The proportion of patients with Glasgow Coma Scale > 8 was slightly higher in the non-motorized group (99% versus 98%, p<0.01), though injury severity did not differ significantly between the two groups. A higher proportion in the motorized group had the most severe injury of contusions and abrasions (56% versus 50%, p<0.01). In contrast, the non-motorized group had a higher proportion of orthopedic injuries (24% versus 16%, p<0.01). The crude mortality rate was 4.51% and 2.15% in the motorized and non-motorized groups, respectively. After controlling for demographic factors and injury severity, the incidence rate ratio of mortality did not differ significantly between motorized and non-motorized trauma groups (IRR 0.91, p=0.35).

Conclusions: Non-motorized vehicular trauma remains a significant proportion of morbidity and mortality resulting from road traffic injuries. The injury severity and incidence rate ratio of mortality did not differ between motorized and non-motorized trauma groups. Health care providers should not underestimate the severity of injuries from non-motorized trauma.
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http://dx.doi.org/10.1016/j.injury.2021.04.035DOI Listing
April 2021

Time to Cannulation after ICU Admission Increases Mortality for Patients Requiring Veno-Venous ECMO for COVID-19 Associated Acute Respiratory Distress Syndrome.

Ann Surg 2020 Dec 22. Epub 2020 Dec 22.

*University of North Carolina at Chapel Hill, Division of Acute Care Surgery, Department of Surgery, Chapel Hill, NC †University of North Carolina at Chapel Hill School of Medicine ‡University of North Carolina at Chapel Hill, Division of Hospital Medicine, Department of Medicine, Chapel Hill, NC §University of North Carolina at Chapel Hill, Division of Acute Care Surgery, Department of General Surgery, Chapel Hill, NC.

Objective: COVID-19 can cause acute respiratory distress syndrome (ARDS) that is rapidly progressive, severe, and refractory to conventional therapies. Extracorporeal membrane oxygenation (ECMO) can be used as a supportive therapy to improve outcomes but evidence-based guidelines have not been defined.

Summary Background Data: Initial mortality rates associated with ECMO for ARDS in COVID-19 were high, leading some to believe that there was no role for ECMO in this viral illness. With more experience, outcomes have improved. The ideal candidate, timing of cannulation, and best post-cannulation management strategy, however, has not yet been defined.

Methods: We conducted a retrospective review from April 1 to July 31 2020 of the first 25 patients with COVID-19 associated ARDS placed on V-V ECMO at our institution. We analyzed the differences between survivors to hospital discharge and those who died. Modified Poisson regression was used to model adjusted risk factors for mortality.

Results: 44% of patients (11/25) survived to hospital discharge. Survivors were significantly younger (40.5 years vs. 53.1 years; p < 0.001) with no differences between cohorts in mean body mass index, diabetes, or PaO2:FiO2 at cannulation. Survivors had shorter duration from symptom onset to cannulation (12.5 days vs. 19.9 days, p = 0.028) and shorter duration of intensive care unit (ICU) length of stay (LOS) prior to cannulation (5.6 days vs. 11.7 days, p = 0.045). Each day from ICU admission to cannulation increased the adjusted risk of death by 4% and each year increase in age increased the adjusted risk 6%.

Conclusions: ECMO has a role in severe, refractory ARDS associated with COVID-19. Increasing age and time from ICU admission were risk factors for mortality and should be considered in patient selection. Further studies are needed to define best practices for V-V ECMO use in COVID-19.
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http://dx.doi.org/10.1097/SLA.0000000000004683DOI Listing
December 2020

The role of endoscopy after upper gastrointestinal bleeding in sub-Saharan Africa: A prospective observational cohort study.

Malawi Med J 2020 09;32(3):139-145

Department of Surgery, University of North Carolina School of Medicine, CB# 7228, Chapel Hill, NC, USA.

Background: Upper gastrointestinal (UGI) bleed is a common surgical disease in sub-Saharan Africa where there is often a lack of diagnostic and interventional adjuncts such as endoscopy. This study sought to characterize the role of endoscopy in management of acute UGI bleeding.

Materials And Methods: This is a prospective observational analysis of adults presenting with an UGI bleed to a tertiary center in Lilongwe, Malawi, over two years. Patients were classified as having no endoscopy, diagnostic endoscopy, or endoscopy with variceal banding. Bivariate, survival analysis, and logistic regression analyses were used to compare intervention cohorts.

Results: 293 patients were included with 49 patients (16.7%) receiving endoscopy with banding, 65 (22.2%) patients receiving diagnostic endoscopy only, and 179 (61.1%) receiving no endoscopy. Upon survival analysis comparing to the no endoscopy group, cox hazard modelling showed an adjusted hazard ratio over 30 days of 0.12 (95% CI 0.02, 0.88, p=0.038) for the endoscopic banding group and a hazard ratio of 0.39 (95% CI 0.13, 1.16, p=0.090) for the diagnostic endoscopy only group. Physical exam findings consistent with cirrhosis and decreasing age were independent predictors of an endoscopic diagnosis of variceal bleeding.

Conclusion: Esophagogastric varices are a common cause of UGI bleeding in sub-Saharan Africa and can be predicted with age and physical exam findings. Endoscopy with variceal banding has a survival benefit for patients presenting with acute UGI bleed even with relatively low utilization. Appropriately triaging patients with likely variceal bleeding and improving endoscopy capacity would likely have a significant impact on mortality.
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http://dx.doi.org/10.4314/mmj.v32i3.6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812143PMC
September 2020

Trends and outcomes following intentional injuries in pediatric patients in a resource-limited setting.

Pediatr Surg Int 2021 May 18;37(5):649-657. Epub 2021 Jan 18.

Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Houpt Physicians' Office Building, Campus Box 7223, 170 Manning Drive, Chapel Hill, NC, 27599-7223, USA.

Introduction: Intentional injuries pose a significant, yet underreported threat to children in sub-Saharan Africa. We sought to evaluate intentional injuries trends and compare outcomes between unintentional and intentional injuries in pediatric patients presenting to a tertiary care facility in Malawi.

Methods: We performed a review of pediatric (≤15 years old) trauma patients presenting to Kamuzu Central Hospital, Lilongwe, Malawi, from 2009 to 2018. Patient characteristics and outcomes were compared based on the injury intent, using bivariate and multivariate regression analysis.

Results: We included 42,600 pediatric trauma patients in the study. Intentional injuries accounted for 5.9% of all injuries. Children with intentional injuries were older (median, 10 vs. 6 years, p < 0.001), more likely to be male (68.4% vs. 63.9%, p < 0.001), and had significantly lower mortality (0.8% vs. 1.4%, p = 0.02) than those with unintentional injuries There was no significant change in the incidence of or mortality associated with intentional injuries. On multivariable regression, increasing age, head and cervical spine injury, night-time presentation, penetrating injury, and alcohol use were associated with increased risk of intentional harm.

Conclusion: Intentional injury remains a significant cause of pediatric trauma in Malawi without decreasing hospital presentation incidence or mortality. In sub-Saharan Africa, there is a need to develop comprehensive plans and policies to protect children.

Level Of Evidence: II.
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http://dx.doi.org/10.1007/s00383-020-04849-zDOI Listing
May 2021

Predictors of multi-drug resistance in burn wound colonization following burn injury in a resource-limited setting.

Burns 2020 Dec 10. Epub 2020 Dec 10.

Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi. Electronic address:

Introduction: Bacterial resistance to antibiotics is growing dramatically worldwide due to several contributing factors, including inappropriate antibiotic utilization in the clinical setting and widespread use in the food production industry. Consequently, it is imperative to characterize antibiotic resistance in high-risk populations, such as burn patients, particularly in resource-limited settings where prevention strategies may be high-yield and new antibiotics are not readily available. We therefore sought to characterize and identify predictors of multi-drug resistant (MDR) bacteria colonization in burn patients at our center in Malawi.

Methods: This is a prospective analysis of burn patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi within 72 h of burn injury. A swab of each patient's primary wound was collected at admission and each subsequent week. The primary aim was to determine predictors of colonization in burn wounds with multi-drug resistant bacteria using modified Poisson regression modeling.

Results: 99 patients were enrolled and analyzed. The median age was 4 years (IQR 2-12) with a median % total burn surface area (TBSA) of 14% (IQR 9-25). The most common burn injury type was scald (n = 61, 61.6%), followed by flame (n = 37, 37.4%). Overall, 54 patients (54.6%) were colonized with MDR bacteria at some point during their hospitalization, with increases each week. For flame burns, the predictors of MDR bacterial colonization were each 1% increase of %TBSA (RR 1.01, 95% CI 1.00, 1.03, p = 0.038) and the use of operative intervention for burn treatment (RR 1.90, 95% CI 1.17, 3.09, p = 0.010). No variables were predictive of MDR wound colonization in scald burns.

Conclusion: Our study identified that almost half of the patients in a Malawian burn unit had MDR bacteria colonizing burn wounds after only a week in the hospital. This increased to almost 70% during hospitalization. We also found that for patients with flame burns, increasing %TBSA, and operative intervention put patients at greater risk of MDR colonization. Interventions such as isolation of burn patients, consistent disinfection and sterilization of wards and operating rooms, and optimization of wound care management are imperative to decrease spread of MDR bacteria and to improve burn-associated clinical outcomes in resource-limited environments.
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http://dx.doi.org/10.1016/j.burns.2020.12.007DOI Listing
December 2020

The gender gap and healthcare: associations between gender roles and factors affecting healthcare access in Central Malawi, June-August 2017.

Arch Public Health 2020 Nov 17;78(1):119. Epub 2020 Nov 17.

Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA.

Background: Women in low and middle-income countries (LMICs) do not have equal access to resources, such as education, employment, or healthcare compared to men. We sought to explore health disparities and associations between gender prioritization, sociocultural factors, and household decision-making in Central Malawi.

Methods: From June-August 2017, a cross-sectional study with 200 participants was conducted in Central Malawi. We evaluated respondents' access to care, prioritization within households, decision-making power, and gender equity which was measured using the Gender-Equitable Men (GEM) scale. Relationships between these outcomes and sociodemographic factors were analyzed using multivariable mixed-effect logistic regression.

Results: We found that women were less likely than men to secure community-sourced healthcare financial aid (68.6% vs. 88.8%, p < 0.001) and more likely to underutilize necessary healthcare (37.2% vs. 22.4%, p = 0.02). Both men and women revealed low GEM scores, indicating adherence to traditional gender norms, though women were significantly less equitable (W:16.77 vs. M:17.65, p = 0.03). Being a woman (Odds Ratio (OR) 0.41, 95% confidence interval (CI) 0.21-0.78) and prioritizing a woman as a decision-maker for large purchases (OR 0.38, CI 0.15-0.93) were independently associated with a lower likelihood of prioritizing women for medical treatment and being a member of the Chewa tribal group (OR 3.87, CI 1.83-8.18) and prioritizing women for education (OR 4.13, CI 2.13-8.01) was associated with a higher odds.

Conclusion: Women report greater barriers to healthcare and adhere to more traditional gender roles than men in this Central Malawian population. Women contribute to their own gender's barriers to care and economic empowerment alone is not enough to correct for these socially constructed roles. We found that education and matriarchal societies may protect against gender disparities. Overall, internal and external gender discrimination contribute to a woman's disproportionate lack of access to care.
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http://dx.doi.org/10.1186/s13690-020-00497-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672876PMC
November 2020

Computed Tomography for Acute Appendicitis Diagnosis and Confirmation in Men : Trends and Cost Implications.

Am Surg 2021 Mar 28;87(3):364-369. Epub 2020 Sep 28.

2331 Department of Surgery, University of North Carolina at Chapel Hill, NC, USA.

Introduction: The classic findings of acute appendicitis-right lower quadrant pain, anorexia, and leukocytosis-have been well known. However, emergency medicine and surgical providers continue to rely on imaging to confirm the diagnosis. We aimed to evaluate the increase in reliance on computed tomography (CT) scans for acute appendicitis diagnosis over time.

Methods: We conducted a retrospective study of patients ≥18 years presenting to UNC Hospitals with signs and symptoms of acute appendicitis who subsequently underwent appendectomy from 2011 to 2015. Demographic, clinical, laboratory, and pathologic data were reviewed. We evaluated the incidence of CT scans stratified by year, age, and sex.

Results: Within our male population, 55.2% (278/504) had classic appendicitis symptoms. Of the 278 male patients with classic appendicitis symptoms, 248 underwent CT imaging. Male patients <45 years of age were more likely to present with classic appendicitis symptoms (216/357, 60.5%) compared with patients aged 46-65 (52/108, 48.1%) or >65 (10/39, 25.6%). Of the male patients <45 years with classic appendicitis symptoms, the incidence of CT scans increased over time (68.3% in 2011, 84.2% in 2012, 92.3% in 2013, 93.9% in 2014, 92.3% in 2015). When considering the 216 CT scans that could have been avoided in our population, we calculate an approximate savings of $173 998.80 over 5 years.

Conclusion: The incidence of CT scans for acute appendicitis confirmation has increased over time even in men. CT scans for the diagnosis or confirmation of acute appendicitis should rarely be indicated in men aged <45 years with classic appendicitis symptoms.
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http://dx.doi.org/10.1177/0003134820951483DOI Listing
March 2021

An invited commentary on "Status of liver transplantation in Latin America" - Current status of liver transplantation in Latin America: Cost, culture and consequences.

Int J Surg 2020 06 23;78:85. Epub 2020 Apr 23.

Department of Surgery, University of North Carolina at Chapel Hill, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ijsu.2020.04.045DOI Listing
June 2020

An Invited Commentary on "World Health Organization declares global emergency: A review of the 2019 novel Coronavirus (COVID-19)": Emergency or new reality?

Int J Surg 2020 04 10;76:111. Epub 2020 Mar 10.

Department of Surgery, University of North Carolina at Chapel Hill, UNC School of Medicine, 4008 Burnett Womack Building, CB 7228, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ijsu.2020.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7129518PMC
April 2020

Secondary Overtriage of Trauma Patients to a Central Hospital in Malawi.

World J Surg 2020 06;44(6):1727-1735

Department of Surgery, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, NC, 27599, USA.

Introduction: Secondary overtriage (OT) is the unnecessary transfer of injured patients between facilities. In low- and middle-income countries (LMICs), which shoulder the greatest burden of trauma globally, the impact of wasted resources on an overburdened system is high. This study determined the rate and associated characteristics of OT at a Malawian central hospital.

Methods: A retrospective analysis of prospectively collected data from January 2012 through July 2017 was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Patients were considered OT if they were discharged alive within 48 h without undergoing a procedure, and were not severely injured or in shock on arrival. Factors evaluated for association with OT included patient demographics, injury characteristics, and transferring facility information.

Results: Of 80,915 KCH trauma patients, 15,422 (19.1%) transferred from another facility. Of these, 8703 (56.2%) were OT. OT patients were younger (median 15, IQR: 6-31 versus median 26, IQR: 11-38, p < 0.001). Patients with primary extremity injury (5308, 59.9%) were overtriaged more than those with head injury (1991, 51.8%) or torso trauma (1349, 50.8%), p < 0.001. The OT rate was lower at night (18.9% v 28.7%, p < 0.001) and similar on weekends (20.4% v 21.8%, p = 0.03). OT was highest for penetrating wounds, bites, and falls; burns were the lowest. In multivariable modeling, risk of OT was greatest for burns and soft tissue injuries.

Conclusions: The majority of trauma patients who transfer to KCH are overtriaged. Implementation of transfer criteria, trauma protocols, and interhospital communication can mitigate the strain of OT in resource-limited settings.
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http://dx.doi.org/10.1007/s00268-020-05426-0DOI Listing
June 2020

Health care disparities in colorectal and esophageal cancer.

Am J Surg 2020 08 23;220(2):415-420. Epub 2019 Dec 23.

Department of Surgery, University of North Carolina, Chapel Hill, NC, USA; Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.

Background: We aimed to identify differences in disparities among patients with a cancer in which screening is widely recommended (colorectal cancer [CRC]) and one in which it is not (esophageal cancer).

Methods: A retrospective analysis was performed using 2004-2015 data from the National Cancer Database. Multivariable generalized logistic regression was used to identify potential differences in the effect of disparities in stage at diagnosis.

Results: A total of 96,524 esophageal cancer patients and 361,187 CRC patients were included. Black patients, longer travel distances, and lower educational attainment were only associated with increased odds of stage IV CRC. While both Medicaid and uninsured patients were more likely to be diagnosed with stage IV esophageal and CRC, the effect was larger among CRC patients. From 2004 to 2015, the rates of stage IV esophageal cancer decreased from 42.0% to 38.2%, while the rates of stage IV CRC increased from 36.9% to 40.8% (p < 0.0001).

Conclusions: Disparities are more pronounced in CRC, compared to esophageal cancer. Equity in access to screening and cancer care should be prioritized.
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http://dx.doi.org/10.1016/j.amjsurg.2019.12.025DOI Listing
August 2020

Risk of Perforation in the Era of Nonemergent Management for Acute Appendicitis.

Am Surg 2019 Nov;85(11):1209-1212

Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to perforation. Recently, studies have suggested nonemergent management of acute appendicitis. Our study aimed to determine changes in risk of rupture and complications in patients with appendicitis, with increasing time from symptom onset to treatment. Retrospective study of patients aged ≥18 years presenting to the University of North Carolina Hospitals with signs and symptoms of acute appendicitis who subsequently underwent appendectomy from 2011 to 2015 was performed. Demographic, clinical, laboratory, and pathologic data were reviewed. Bivariate analysis was performed to assess variables associated with increased risk of perforation. Poisson regression modeling was completed to evaluate the risk of perforation and postoperative abscess based on time from symptoms to treatment. Within our database of 1007 patients, the mean time from onset of symptoms to operative intervention was 3.24 ± 2.2 days. Modified Poisson regression modeling demonstrated the relative risk for perforation increases by 9% (RR 1.09, < 0.001) for each day delay. Age (RR 1.03), male gender (RR 1.50), temperature on admission (RR 1.32), and the presence of fecalith (RR 1.89) statistically significantly increased the risk of perforation. Furthermore, for each day delay, there is an 8% increased risk of postoperative abscess (RR 1.08, = 0.027). The relative risk for appendiceal perforation is 9 per cent per day delay with a resultant 8 per cent increased risk of postoperative abscess. Thus, appendectomy for acute appendicitis should remain an emergent procedure, given that delays in operative management lead to complications and increases in cost of care.
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November 2019

Transitions in surgical education.

Surgery 2020 06 13;167(6):895-898. Epub 2019 Nov 13.

Department of Surgery, The University of North Carolina at Chapel Hill School of Medicine, NC.

There are multiple transitions in surgical education. Among the most significant are those from medical student to intern, from junior resident to senior resident, and from senior resident/fellow to independent practice. While there are new expectations and responsibilities associated with each of these roles, a surgeon's development should be thought of as more of a continuum with distinct points of greatest change and challenge. There are common themes at these various transitions that may be highlighted for both trainees and educators.
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http://dx.doi.org/10.1016/j.surg.2019.08.024DOI Listing
June 2020

Appendiceal Malignancy: The Hidden Risks of Nonoperative Management for Acute Appendicitis.

Am Surg 2019 Feb;85(2):223-225

One potential harm of nonoperative management for acute appendicitis is missed appendiceal cancer, a rare and often aggressive malignancy due to the frequency of late stage of diagnosis. Previous studies have reported an increasing incidence of appendiceal neoplasms in the population. This is a retrospective case-control study of 1007 adult patients, who presented to the University of North Carolina-Memorial Hospital (UNC-MH) between 2011 and 2015 with clinical signs and symptoms of appendicitis. We evaluated the incidence of primary appendiceal cancer in this population and determined factors that predict appendiceal cancer diagnosis using multivariate logistic regression analysis. The overall incidence of appendiceal neoplasm for adult patients presenting to UNC-MH with appendicitis from 2011 to 2015 was 2.3 per cent (23/1007). The incidence in patients without appendiceal perforation on pathology was 1.9 per cent (16/832). Age (odds ratio (OR) 1.03), number of days of abdominal pain (OR 1.16), self-reported fever (OR 2.08), appendiceal width (OR 1.95), and appendiceal wall thickness (OR 1.30) were predictors of appendiceal neoplasm diagnosis in patients that present with acute appendicitis. We recommend that an operative approach to acute appendicitis should remain the standard of care because operative management may not only be diagnostic but potentially therapeutic.
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February 2019

Interpersonal violence in peacetime Malawi.

Trauma Surg Acute Care Open 2018 27;3(1):e000252. Epub 2018 Dec 27.

Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Background: The contribution of interpersonal violence (IPV) to trauma burden varies greatly by region. The high rates of IPV in sub-Saharan Africa are thought to relate in part to the high rates of collective violence. Malawi, a country with no history of internal collective violence, provides an excellent setting to evaluate whether collective violence drives the high rates of IPV in this region.

Methods: This is a retrospective review of a prospective trauma registry from 2009 through 2016 at Kamuzu Central Hospital in Lilongwe, Malawi. Adult (>16 years) victims of IPV were compared with non-intentional trauma victims. Log binomial regression determined factors associated with increased risk of mortality for victims of IPV.

Results: Of 72 488 trauma patients, 25 008 (34.5%) suffered IPV. Victims of IPV were more often male (80.2% vs. 74.8%; p<0.001), younger (median age: 28 years (IQR: 23-34) vs. 30 years (IQR: 24-39); p<0.001), and were more often admitted at night (47.4% vs. 31.9%; p<0.001). Of the IPV victims, 16.5% admitted alcohol use, compared with only 4.4% in other trauma victims (p<0.001). In regression modeling, compared with extremity injuries, head injuries (3.14, 2.24-4.39; p<0.001) and torso injuries (4.32, 2.98-6.27; p<0.001) had increased risk of mortality. Compared with other or unknown mechanisms, penetrating injuries also had increased risk of mortality (1.46, 95% CI 1.17 to 1.81, p=0.001). Alcohol use was associated with a lower risk of mortality (0.54, 95% CI 0.39 to 0.75; p<0.001).

Discussion: Even in a sub-Saharan country that never experienced internal collective violence, IPV injury rates are high. Public health efforts to measure and address alcohol use, and studies to determine the role of "mob justice," poverty, and intimate partner violence in IPV, in Malawi are needed.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1136/tsaco-2018-000252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326358PMC
December 2018

Cholecystectomy Vs. Cholecystostomy for the Management of Acute Cholecystitis in Elderly Patients.

J Gastrointest Surg 2019 03 17;23(3):503-509. Epub 2018 Sep 17.

Department of Surgery, University of North Carolina at Chapel Hill, 4030 Burnett Womack Building, 101 Manning Drive, CB 7081, Chapel Hill, NC, 27599-7081, USA.

Background: Data comparing outcomes following cholecystectomy and cholecystostomy tube placement (CTP) in elderly patients are lacking. We aimed to compare the post-procedural outcomes between cholecystectomy and CTP in elderly patients with acute cholecystitis.

Methods: We performed a retrospective, population-based analysis using the National Inpatient Sample for the period 2000-2014. Patients ≥ 65 years old admitted with a primary diagnosis of acute cholecystitis and who underwent either cholecystectomy or CTP during their hospitalization were included. Multivariable linear and logistic regression models were used to analyze post-procedural complications, mortality, length of stay, and total charges. The effect of procedure type on patient outcomes, stratified by acalculous and calculous cholecystitis, was also performed.

Results: A total of 200,915 patients were included, of which 7516 underwent CTP and 193,399 underwent cholecystectomy. The median age of patients undergoing CTP and cholecystectomy was 80 (IQR 73-87) and 75 (IQR 70-81), respectively. Patients undergoing CTP were more likely to have post-procedural infection (OR 2.25; 95% CI 2.07, 2.45), bleeding (OR 1.28; 95% CI 1.19, 1.37), and inpatient mortality (OR 9.27; 95% CI 7.95, 10.81). On average, CTP patients stayed 1.25 days longer (95% CI 1.14, 1.37) in hospital after the procedure. The benefits of cholecystectomy were consistent in patients with acalculous and calculous cholecystitis.

Conclusions: Elderly patients with both acalculous and calculous acute cholecystitis managed with CTP have higher incidences of post-procedural morbidity and mortality, and longer post-procedure length of hospital stay, as compared to cholecystectomy. Unless prohibitive surgical risks exist, elderly patients with acute cholecystitis should undergo cholecystectomy.
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http://dx.doi.org/10.1007/s11605-018-3863-1DOI Listing
March 2019

Sex Disparities in Access to Surgical Care at a Single Institution in Malawi.

World J Surg 2019 01;43(1):60-66

Department of Surgery, University of North Carolina- Chapel Hill, 4001 Burnett-Womack Building CB# 7050, Chapel Hill, NC, 27599-7050, USA.

Introduction: There is a paucity of data regarding sex-based disparities in surgical care delivery, particularly in low- and middle-income countries. This study sought to determine whether sex disparities are present among patients presenting with surgical conditions in Malawi. Hypothesis compared to men, fewer women present to Kamuzu Central Hospital (KCH) with peritonitis and have longer delays in presentation for definitive care.

Methods: This study performs a retrospective analysis of prospectively collected data of all general surgery patients with peritonitis presenting to KCH in Lilongwe, Malawi, from September 2013 to April 2016. Multivariable linear and logistic regressions were used to assess the effect of sex on mortality, length of stay, operative intervention, complications, and time to presentation.

Results: Of 462 patients presenting with general surgery conditions and peritonitis, 68.8% were men and 31.2% were women. After adjustments, women had significantly higher odds of non-operative management when compared to men (OR 2.17, 95%CI 1.30-3.62, P = 0.003), delays in presentation (adjusted mean difference 136 h, 95%CI 100-641, P = 0.05), delays to operation (adjusted mean difference 1.91 days, 95%CI 1.12-3.27, P = 0.02), and longer lengths of stay (adjusted mean difference 1.67 days, 95%CI 1.00-2.80, P = 0.05). There were no differences in complications or in-hospital or Emergency Department mortality.

Conclusion: Sex disparities exist within the general surgery population at KCH in Lilongwe, Malawi. Fewer women present with surgical problems, and women experience delays in presentation, longer lengths of stay, and undergo fewer operations. Future studies to determine mortality in the community and driving factors of sex disparities will provide more insight.
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http://dx.doi.org/10.1007/s00268-018-4775-7DOI Listing
January 2019

Road traffic collisions in Malawi: Trends and patterns of mortality on scene.

Malawi Med J 2017 12;29(4):301-305

Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.

Background: Worldwide, 90% of injury deaths occur in low- and middle-income countries (LMIC). Road traffic collisions (RTCs) are increasingly common and result in more death and disability in the developing world than in the developed world. We aimed to examine the pre-hospital case fatality rate from RTCs in Malawi.

Material And Methods: A retrospective study was performed utilizing the Malawian National Road Safety Council (NRSC) registry from 2008-2012. The NRSC data were collected at the scene by police officers. Victim, vehicle, and environmental factors were used to describe the characteristics of fatal collisions. Case fatality rate was defined as the number of fatalities divided by the number of people involved in RTCs each year. Logistic regression analysis was used to determine predictors of crash scene fatality.

Results: A total of 11,467 RTCs were reported by the NRSC between 2008 and 2012. Of these, 34% involved at least one fatality at the scene. The average age of fatalities was 32 years and 82% were male. Drivers of motor vehicles had the lowest odds of mortality following RTCs. Compared to drivers; pedestrians had the highest odds of mortality (OR 39, 95% CI 34, 45) followed by bicyclists (OR 26, 95% CI 22, 31). The average case fatality rate was 17% /year, and showed an increased throughout the study period.

Conclusions: RTCs are a common cause of injury in Malawi. Approximately one-third of RTCs involved at least one death at the scene. Pedestrians were particularly vulnerable, exhibiting very high odds of mortality when involved in a road traffic collision. We encourage the use of these data to develop strategies in LMIC countries to protect pedestrians and other road users from RTCs.
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http://dx.doi.org/10.4314/mmj.v29i4.4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6019546PMC
December 2017

Challenges of centralizing cancer care in the US.

Int J Surg 2018 07 5;55:209-210. Epub 2018 May 5.

Department of Surgery, University of North Carolina, Chapel Hill, NC, USA; Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1016/j.ijsu.2018.05.002DOI Listing
July 2018

Colonization with Multidrug-Resistant Enterobacteriaceae is Associated with Increased Mortality Following Burn Injury in Sub-Saharan Africa.

World J Surg 2018 10;42(10):3089-3096

Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.

Background: Multidrug-resistant (MDR) bacteria are an emerging international concern in low- and middle-income countries that threaten recent public health gains. These challenges are exacerbated in immunocompromised hosts, such as those with burn injury. This study sought to describe the epidemiology and associated clinical outcomes of burn wound colonization in a Malawian tertiary burn center.

Methods: This is a prospective analysis of burn patients presenting to Kamuzu Central Hospital in Lilongwe, Malawi, within 72 h of burn injury. A swab of each patient's primary wound was collected at admission and each subsequent week. The primary exposure was burn wound colonization with MDR bacteria, particularly Enterobacteriaceae. The primary outcome was in-hospital mortality. A log binomial model estimated the association between the exposure and outcome, adjusted for confounders.

Results: Ninety-nine patients were enrolled with a median age of 4 years (IQR 2-12) and a male preponderance (54%). Median total body surface area burn (TBSA) was 14% (IQR 9-25), and crude in-hospital mortality was 19%. Enterobacteriaceae were the most common MDR bacteria with 36% of patients becoming colonized. Wound colonization with MDR Enterobacteriaceae was associated with increased in-hospital mortality with a risk ratio of 1.86 (95% CI 1.38, 2.50, p < 0.001) adjusted for TBSA, burn type (scald vs. flame), sex, age, length of stay, and methicillin-resistant Staphylococcus aureus colonization.

Conclusion: MDR bacteria, especially Enterobacteriaceae, are common and are associated with worse burn injury outcomes. In resource-poor environments, a greater emphasis on prevention of MDR bacterial colonization, improved isolation precautions, affordable diagnostics, and antibiotic stewardship are imperative.
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http://dx.doi.org/10.1007/s00268-018-4633-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128739PMC
October 2018

Burn injury mortality in patients with preexisting and new onset renal disease.

Am J Surg 2018 06 1;215(6):1011-1015. Epub 2018 Mar 1.

Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, USA. Electronic address:

Introduction: We sought to examine the impact of preexisting and new onset renal disease on burn injury mortality.

Methods: Retrospective analysis of patients admitted to a regional burn center from 2002-2012 was performed. Variables analyzed included demographics, burn mechanism, inhalation injury status, and % TBSA. Poisson regression was performed to estimate risk of in-hospital burn mortality.

Results: There were a total of 7640 patients over the study period. The adjusted 60-day risk of in-hospital mortality in patients with preexisting renal disease (PRD was 3 times higher compared to patients with no preexisting renal disease (IRR = 3.22, 95% CI = 1.26-8.25). The adjusted 60-day risk of mortality is 2 times higher for patients with new onset renal disease compared to those without (IRR = 2.11, 95% CI = 1.55-2.87).

Conclusion: Preexisting and new onset renal disease results in a significantly higher risk of mortality following burn injury compared to patients without renal disease. Prevention of new onset renal injury and careful management of patients with preexisting renal disease to prevent exacerbation should be pursued.
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http://dx.doi.org/10.1016/j.amjsurg.2018.02.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855245PMC
June 2018

Esophageal Cancer Surgery: Spontaneous Centralization in the US Contributed to Reduce Mortality Without Causing Health Disparities.

Ann Surg Oncol 2018 Jun 18;25(6):1580-1587. Epub 2018 Jan 18.

Department of Surgery, University of North Carolina at Chapel Hill, 4030 Burnett Womack Building 101 Manning Drive, CB 7081, Chapel Hill, NC, 27599-7081, USA.

Background: Improvement in mortality has been shown for esophagectomies performed at high-volume centers.

Objective: This study aimed to determine if centralization of esophageal cancer surgery occurred in the US, and to establish its impact on postoperative mortality. In addition, we aimed to analyze the relationship between regionalization of cancer care and health disparities.

Methods: A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2014. Adult patients (≥ 18 years of age) diagnosed with esophageal cancer and who underwent esophagectomy were included. Yearly hospital volume was categorized as low (< 5 procedures), intermediate (5-20 procedures), and high (> 20 procedures). Multivariable analyses on the potential effect of hospital volume on patient outcomes were performed, and the yearly rate of esophagectomies was estimated using Poisson regression.

Results: A total of 5235 patients were included. Esophagectomy at low- [odds ratio (OR) 2.17] and intermediate-volume (OR 1.62) hospitals, compared with high-volume hospitals, was associated with a significant increase in mortality. The percentage of esophagectomies performed at high-volume centers significantly increased during the study period (29.2-68.5%; p < 0.0001). The trend towards high-volume hospitals was different among the different US regions: South (7.7-54.3%), West (15.0-67.6%), Midwest (37.3-67.7%), and Northeast (55.8-86.8%) [p < 0.0001]. Overall, the mortality rate of esophagectomy dropped from 10.0 to 3.5% (p = 0.006), with non-White race, public insurance, and low household income patients also showing a significant reduction in mortality.

Conclusions: A spontaneous centralization for esophageal cancer surgery occurred in the US. This process was associated with a decrease in the mortality rate, without contributing to health disparities.
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http://dx.doi.org/10.1245/s10434-018-6339-3DOI Listing
June 2018

Advancing Global Surgery: Moving Beyond Identifying Problems to Finding Solutions.

World J Surg 2017 12;41(12):2979-2980

University of Washington, Seattle, WA, USA.

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http://dx.doi.org/10.1007/s00268-017-4316-9DOI Listing
December 2017

Routine computed tomography after recent operative exploration for penetrating trauma: What injuries do we miss?

J Trauma Acute Care Surg 2017 10;83(4):575-578

From the Division of Trauma and Critical Care, Department of Surgery (A.E.M., C.A.W., A.C., M.M.K.), University of California San Francisco, San Francisco, California; and Department of Surgery (A.G.C., B.A.C.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Patients with penetrating trauma who cannot be stabilized undergo operative intervention without preoperative imaging. In such cases, postoperative imaging may reveal additional injuries not identified during the initial operative exploration. The purpose of this study is to explore the utility of postoperative CT imaging in the setting of penetrating trauma.

Methods: This was a retrospective analysis of patients with penetrating trauma treated at an urban Level 1 trauma center between 2010 and 2015. Patients were included if they underwent an emergent laparotomy without preoperative imaging. Patients were excluded if they had prior imaging or concomitant blunt injury. For the purposes of this study, occult injury was defined as a CT scan finding not mentioned in the first operative report. Descriptive statistics were used to compare patient characteristics who had received imaging immediately postoperatively with those who had not.

Results: During the 5-year study period, 328 patients who had a laparotomy for penetrating trauma over the study period, 225 patients met the inclusion criteria. Seventy-three (32%) patients underwent CT scanning immediately postoperatively with occult injuries identified in 38 (52%) patients. The most frequent occult injuries were orthopedic (20 of 43) and genitourinary (9 of 43). Importantly, 10 (26%) of the 38 patients required an intervention for these occult injuries. Those selected for immediate postoperative imaging were more likely to have sustained gunshot wounds and were significantly more severely injured (higher Injury Severity Score and longer length of hospital stay) when compared to patients who did not receive immediate imaging.

Conclusion: We recommend the use of immediate postoperative CT after emergent laparotomy especially when there is a high index of suspicion for spine or genitourinary injuries and in patients who have sustained ballistic penetrating injuries.

Level Of Evidence: Therapeutic/care management, level IV; diagnostic tests or criteria, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001558DOI Listing
October 2017

Colostomy as a Bridge to Definitive Pediatric Surgical Care: A Sub-Saharan African Experience.

Am Surg 2017 Sep;83(9):e367-e369

Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA.

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September 2017

Task Shifting: The Use of Laypersons for Acquisition of Vital Signs Data for Clinical Decision Making in the Emergency Room Following Traumatic Injury.

World J Surg 2017 12;41(12):3066-3073

UNC Project, Lilongwe, Malawi.

Importance: In resource-limited settings, identification of successful and sustainable task-shifting interventions is important for improving care.

Objective: To determine whether the training of lay people to take vital signs as trauma clerks is an effective and sustainable method to increase availability of vital signs in the initial evaluation of trauma patients.

Design: We conducted a quasi-experimental study of patients presenting with traumatic injury pre- and post-intervention.

Setting: The study was conducted at Kamuzu Central Hospital, a tertiary care referral hospital, in Lilongwe, Malawi.

Participants: All adult (age ≥ 18 years) trauma patients presenting to emergency department over a six-month period from January to June prior to intervention (2011), immediately post-intervention (2012), 1 year post-intervention (2013) and 2 years post-intervention (2014).

Intervention: Lay people were trained to take and record vital signs.

Main Outcomes And Measures: The number of patients with recorded vital signs pre- and post-intervention and sustainability of the intervention as determined by time-series analysis.

Results: Availability of vital signs on initial evaluation of trauma patients increased significantly post-intervention. The percentage of patients with at least one vital sign recorded increased from 23.5 to 92.1%, and the percentage of patients with all vital signs recorded increased from 4.1 to 91.4%. Availability of Glasgow Coma Scale also increased from 40.3 to 88.6%. Increased documentation of vital signs continued at 1 year and 2 years post-intervention. However, the percentage of documented vital signs did decrease slightly after the US-trained medical student and surgeon who trained the trauma clerks were no longer available in country, except for Glasgow Coma Scale. Patients who died during emergency department evaluation were significantly less likely to have vital signs recorded.

Conclusions And Relevance: The training of lay people to collect vital signs and Glasgow Coma Scale is an effective and sustainable method of task shifting in a resource-limited setting.
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http://dx.doi.org/10.1007/s00268-017-4121-5DOI Listing
December 2017

Management of Pulmonary Failure after Burn Injury: From VDR to ECMO.

Clin Plast Surg 2017 Jul;44(3):513-520

Department of Surgery, University of North Carolina School of Medicine, Suite 7038, Burnett Womack, CB#7195, Chapel Hill, NC 27599, USA. Electronic address:

This article highlights the challenges in managing pulmonary failure after burn injury. The authors review several different ventilator techniques, provide weaning parameters, and discuss complications.
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http://dx.doi.org/10.1016/j.cps.2017.02.011DOI Listing
July 2017

Burn Care in Low- and Middle-Income Countries.

Clin Plast Surg 2017 Jul 14;44(3):479-483. Epub 2017 Apr 14.

Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina at Chapel Hill, 4004 Burnett Womack Building, 101 Manning Drive, Chapel Hill, NC 27599, USA.

This article examines the societal impact of thermal injury in low- and middle-income countries. The authors describe the unique challenges of these health care systems in providing care for burned patients, focusing on resuscitation, excision and grafting, rehabilitation, and reconstruction.
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http://dx.doi.org/10.1016/j.cps.2017.02.007DOI Listing
July 2017