BACKGROUND:One third of organ donors suffer catastrophic brain injury (CBI). There are no standard guidelines for the management of traumatic CBI prior to brain death, and not all trauma centers have institutional CBI guidelines. In addition, there is high variability in management between institutions with guidelines. Catastrophic brain injury guidelines vary and may include various combinations of hormone therapy, vasopressors, fluid resuscitation, and other practices. We hypothesized that centers with CBI guidelines have higher organ donation rates than those without. METHODS:This prospective, observational EAST-sponsored multicenter trial included adult (18+ years old) traumatic-mechanism CBI patients at 33 level I and II trauma centers from January 2022 to May 2023. Catastrophic brain injury was defined as a brain injury causing loss of function above the brain stem and subsequent death. Cluster analysis with linear mixed-effects model including UNOS regions and hospital size by bed count was used to determine whether CBI guidelines are associated with organ donation. RESULTS:A total of 790 CBI patients were included in this analysis. In unadjusted comparison, CBI guideline centers had higher rates of organ donation and use of steroids, whole blood, and hormone therapy. In a linear mixed-effects model, CBI guidelines were not associated with organ donation. Registered organ donor status, steroid hormones, and vasopressin were associated with increased relative risk of donation. CONCLUSION:There is high variability in management of CBI, even at centers with CBI guidelines in place. While the use of institutional CBI guidelines was not associated with increased organ donation, guidelines in this study were not identical. Hormone replacement with steroids and vasopressin was associated with increased donation. Hormone resuscitation is a common feature of CBI guidelines. Further analysis of individual practices that increase organ donation after CBI may allow for more effective guidelines and an overall increase in donation to decrease the long waiting periods for organ transplant recipients. LEVEL OF EVIDENCE:Prognostic and Epidemiological; Level II.

Malawi has the second-highest cervical cancer incidence and mortality rate in the world. In 2019, the National Service Delivery Guidelines for Cervical Cancer Prevention and Control were published to provide evidence-based recommendations for cervical cancer screening and treatment for the local environment in Malawi, in alignment with the 2016–2020 National Cervical Cancer Control Strategy. Guidelines include primary (vaccination and education) and secondary (early detection and treatment of early lesions) prevention strategies (Figure). We assessed the extent of implementation of these guidelines at a rural Malawian healthcare institution serving 721,456 (2018 census) patients in Thyolo District, Southern Region, Malawi. This location was one of 316 screening sites in the country and one of the earliest to implement Pap smears in Malawi. A retrospective review of cervical cancer screening clinic records from 2016 to 2021 was performed. Abstracted data were derived from available hand-written records and included the number of patients screened, the type of screening performed, and patient age and HIV status. Collected screening outcomes were assessed for congruency with established Malawian guidelines. Overall, 15,350 patients were screened, including 7188 (46.8%) with visual inspection with acetic acid (VIA) and 8045 (52.4%) with Pap tests; the remaining 117 (0.76%) were screened by speculum exam alone or not documented. HIV data (available after 2017) showed that 6339/14,103 (45%) screened patients were HIV positive. The total number of women screened between January 2016 and December 2019 was 10,004. During this time period, screening records were insufficient for detailed reporting due to missing data. The total number of women screened in 2020–2021 was 5346. In 2020–2021, VIA was performed in 296/1223 (24%) patients aged >50 years. Pap tests were performed in 144/4107 (3.5%) patients <50 years. A total of 409 patients were screened before the age of 25. Between the period of November 2019 to December 2021, 14 of the examined patients had documented visualized cervical human papillomavirus (HPV) changes. Few patients underwent immediate treatment, i.e., "screen and treat" (n = 14, January 2019–December 2021). At one of the first institutions in Malawi to provide Pap smears as a screening option, HIV prevalence is as high as 45%. Over time, there has been increased implementation and documentation of cervical cancer screening guidelines. Opportunities to narrow existing gaps in care remain. Utilization of HPV testing as a screening strategy remains low, despite national Malawi guideline recommendations for such. Deviation from the guidelines regarding VIA utilization in women over 50 is still noted. Future efforts towards improved documentation will help identify barriers to implementing guidelines appropriate for low-resource settings. Further research is needed to assess the completeness of coverage provided by the screening services for the surrounding region and to fully implement the cervical cancer control strategy in Malawi.

Malawi's HIV prevalence of 8.9% among adults is one of the highest in the world; women constitute 62% of HIV positive (HIV+) patients and 37% of all cancers in Malawi women are cervical. The highest HIV prevalence (HIVP) is in the Southwest region at 14% where this study took place. We investigated the outcomes of cervical cancer screening, stratified by HIV status, for patients seen at a single rural hospital in Malawi. Cervical cancer screening clinic records from 2016–2021 at a single rural hospital were retrospectively reviewed for number of patients screened per month and year, age category, and HIV status. HIVP was compared to reported national Malawian data. Abstracted cervical cancer screening parameters included: type of screening (Pap vs visual inspection with acetic acid (VIA), speculum exam only, not documented) and screening results (normal vs abnormal). In total, 15,432 patient records were available for review. HIV status was available starting January 2017; of 14,185 patients screened for cervical cancer, 6,339 (44.7%) were HIV+. When stratified by year (Table 1), HIVP in screened population rose from 1.8% (2017) to 23% (2018), 39% (2019), 59% (2020), and finally 82% (2021). HIVP stratified by age was available starting in 2020: in patients screened in 2020, HIVP was 25% in women age <25, 64.5% in women age 25–49, and 58.9% in women age >49. In 2021, HIVP was 56.7% in women age <25, 83.5% in women age 25–49, and 84.1% in women age >49. Abnormal screenings were more frequent in HIV+ patients between 2017–2020 (Table 1), but this trend reversed in 2021. Of note, the COVID pandemic peaked in 2021 in Malawi. In 2021, there was a higher absolute number of abnormal screens in HIV+ patients compared to HIV– patients (61 vs 21). HIVP in this cohort is 45%; national HIVP is 10.8% among women 15–49. Documented HIVP in the clinic population increased from 1.8% to 82% between 2017 and 2021. Cervical abnormalities were more frequent in HIV+ than HIV– patients. Enrichment of the patient cohort with HIV+ cases may be due to a decreasing likelihood of HIV- patients seeking screening during the COVID-19 pandemic, as well as implementation of HIV control guidelines with resultant testing and diagnosis leading to increased referrals for secondary disease process screening (cervical cancer in this case). Table: HIV prevalence by age and screening method among women screened for cervical cancer at a single institution in the Southern Region, Malawi, 2017–2021. Download : Download high-res image (342KB)Download : Download full-size image

Cervical cancer is the most common cancer diagnosis in Malawi women, with an estimated 2314 deaths per year. Malawi has one of the leading age-standardized rates of cervical cancer in the world and a high prevalence of HIV. In 2012, a hospital in Southern Malawi was the first rural facility to offer screening Pap tests in Malawi. From 2016 through 2021, cervical cancer awareness and screening efforts increased across the country. We aimed to assess the total number of patients screened from 2016 to 2021 at a single institution and to quantify the number of cervical cancer diagnoses. Additionally, we aimed to ascertain the impact of the COVID-19 pandemic on cervical cancer screening.