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Mwale D, Manda-Taylor L, Langton J, Likumbo A, van Hensbroek MB, Calis J, Janssens W, Pell C. The role of healthcare providers and caregivers in monitoring critically ill children: a qualitative study in a tertiary hospital, southern Malawi. BMC Health Serv Res 2024; 24:595. [PMID: 38714998 PMCID: PMC11077805 DOI: 10.1186/s12913-024-11050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Critically ill children require close monitoring to facilitate timely interventions throughout their hospitalisation. In low- and middle-income countries with a high disease burden, scarce paediatric critical care resources complicates effective monitoring. This study describes the monitoring practices for critically ill children in a paediatric high-dependency unit (HDU) in Malawi and examines factors affecting this vital process. METHODS A formative qualitative study based on 21 in-depth interviews of healthcare providers (n = 12) and caregivers of critically ill children (n = 9) in the HDU along with structured observations of the monitoring process. Interviews were transcribed and translated for thematic content analysis. RESULTS The monitoring of critically ill children admitted to the HDU was intermittent, using devices and through clinical observations. Healthcare providers prioritised the most critically ill children for more frequent monitoring. The ward layout, power outages, lack of human resources and limited familiarity with available monitoring devices, affected monitoring. Caregivers, who were present throughout admission, were involved informally in monitoring and flagging possible deterioration of their child to the healthcare staff. CONCLUSION Barriers to the monitoring of critically ill children in the HDU were related to ward layout and infrastructure, availability of accurate monitoring devices and limited human resources. Potential interventions include training healthcare providers to prioritise the most critically ill children, allocate and effectively employ available devices, and supporting caregivers to play a more formal role in escalation.
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Affiliation(s)
- Daniel Mwale
- Kamuzu University of Health Sciences, Blantyre, Malawi.
- Training Research Unit of Excellence, Blantyre, Malawi.
| | - Lucinda Manda-Taylor
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Training Research Unit of Excellence, Blantyre, Malawi
| | | | - Alice Likumbo
- Training Research Unit of Excellence, Blantyre, Malawi
| | - Michael Boele van Hensbroek
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
| | - Job Calis
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciencies, Blantyre, Malawi
| | - Wendy Janssens
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Economics, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health Amsterdam, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Kumwenda M, Assies R, Snik I, Chatima G, Langton J, Chimalizeni Y, Romaine ST, van Woensel JB, Pallmann P, Carrol ED, Calis JC. Identifying critically ill children in Malawi: A modified qSOFA score for low-resource settings. PLOS Glob Public Health 2024; 4:e0002388. [PMID: 38271303 PMCID: PMC10810502 DOI: 10.1371/journal.pgph.0002388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024]
Abstract
In low-resource settings, a reliable bedside score for timely identification of children at risk of dying, could help focus resources and improve survival. The rapid bedside Liverpool quick Sequential Organ Failure Assessment (LqSOFA) uses clinical parameters only and performed well in United Kingdom cohorts. A similarly quick clinical assessment-only score has however not yet been developed for paediatric populations in sub-Saharan Africa. In a development cohort of critically ill children in Malawi, we calculated the LqSOFA scores using age-adjusted heart rate and respiratory rate, capillary refill time and Blantyre Coma Scale, and evaluated its prognostic performance for mortality. An improved score, the Blantyre qSOFA (BqSOFA), was developed (omitting heart rate, adjusting respiratory rate cut-off values and adding pallor), subsequently validated in a second cohort of Malawian children, and compared with an existing score (FEAST-PET). Prognostic performance for mortality was evaluated using area under the receiver operating characteristic curve (AUC). Mortality was 15.4% in the development (N = 493) and 22.0% in the validation cohort (N = 377). In the development cohort, discriminative ability (AUC) of the LqSOFA to predict mortality was 0.68 (95%-CI: 0.60-0.76). The BqSOFA and FEAST-PET yielded AUCs of 0.84 (95%-CI:0.79-0.89) and 0.83 (95%-CI:0.77-0.89) in the development cohort, and 0.74 (95%-CI:0.68-0.79) and 0.76 (95%-CI:0.70-0.82) in the validation cohort, respectively. We developed a simple prognostic score for Malawian children based on four clinical parameters which performed as well as a more complex score. The BqSOFA might be used to promptly identify critically ill children at risk of dying and prioritize hospital care in low-resource settings.
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Affiliation(s)
- Mercy Kumwenda
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Paediatrics and Child Health, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Roxanne Assies
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Global Health and Quality of Care, Amsterdam, the Netherlands
| | - Ilse Snik
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Gloria Chatima
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Yamikani Chimalizeni
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sam T. Romaine
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Job B.M. van Woensel
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Global Health and Quality of Care, Amsterdam, the Netherlands
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Enitan D. Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Job C.J. Calis
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Global Health and PICU, Amsterdam Institute for Global Health and Development and Emma Children’s Hospital, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Global Health and Quality of Care, Amsterdam, the Netherlands
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Kumwenda M, Assies R, Chathima G, Khofi H, van Woensel JBM, Chimalizeni Y, Langton J, Calis JCJ. Prevalence, mortality, and aetiology of paediatric shock in a tertiary hospital in Malawi: A cohort study. PLOS Glob Public Health 2024; 4:e0002282. [PMID: 38190409 PMCID: PMC10773928 DOI: 10.1371/journal.pgph.0002282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 11/18/2023] [Indexed: 01/10/2024]
Abstract
Shock is considered one of the most important mechanisms of critical illness in children. However, data on paediatric shock in sub-Saharan Africa is limited, which constrains development of effective treatment strategies. We aimed to describe the prevalence, mortality, and aetiology of paediatric shock in a tertiary hospital in Malawi. Children aged two months to 16 years presenting with shock (FEAST criteria; respiratory distress and/or impaired consciousness, and at least one sign of impaired circulation; capillary refill>3 seconds, cold extremities, weak pulse, or severe tachycardia) to the emergency department were included and followed-up prospectively using routinely collected data between February 2019 and January 2020. Prevalence, mortality and aetiology of shock were reported for both the FEAST criteria and World Health Organization (WHO) definition. The association between aetiology and mortality was assessed with univariable analysis. Of all screened admissions (N = 12,840), 679 (5.3%) children presented with shock using FEAST criteria and the mortality was 79/663 (11.9%). WHO-defined shock applied to 16/12,840 (0.1%) and the mortality was 9/15 (60.0%). Main diagnoses were viral/reactive airway diseases (40.4%), severe pneumonia (14.3%), gastroenteritis (11.3%) and presumed sepsis (5.7%). Children diagnosed with presumed sepsis and gastroenteritis had the highest odds of dying (OR 11.3; 95%-CI:4.9-25.8 and OR 4.4; 95%-CI:2.4-8.2). Considering the high mortality, prevalence of paediatric shock (FEAST and WHO definitions) in Malawi is high. Sepsis and gastroenteritis are diagnoses associated with poor outcome in these children. Consensus on a clinical meaningful definition for paediatric shock is essential to boost future studies.
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Affiliation(s)
- Mercy Kumwenda
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Paediatrics and Child Health, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Roxanne Assies
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- PICU, Emma Children’s Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Gloria Chathima
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Harriet Khofi
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Job B. M. van Woensel
- PICU, Emma Children’s Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Yamikani Chimalizeni
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Job C. J. Calis
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- PICU, Emma Children’s Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
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Langton J, Liaghati-Mobarhan S, Gicheha E, Werdenberg-Hall J, Madete J, Banda G, Molyneux EM. Using interprofessional education to build dynamic teams to help drive collaborative, coordinated and effective newborn care. BMC Pediatr 2023; 23:565. [PMID: 37968582 PMCID: PMC10647162 DOI: 10.1186/s12887-023-04373-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 10/17/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND As countries strive to achieve sustainable development goal 3.2, high-quality medical education is crucial for high-quality neonatal care. Women are encouraged to deliver in health units attended by a skilled team. Traditionally, the team is doctors and nurses, but they are members of a large group of interdependent experts from other disciplines. Each discipline trains separately, yet the goal of good neonatal care is common to all. The use of interprofessional education breaks down these professional silos improving collaborative practice and promoting excellent clinical care. Introduction of new educational materials and training requires a rigorous approach to ensure sustainability. METHODS An extensive needs assessment identified gaps in neonatal training. Specifically, there was a lack of inclusion of medical devices used in clinical care. In each country, national key stakeholders came together to develop and revise their own neonatal curricula, trainings or guidelines. A core writing education team were tasked to develop evidence-based materials on pertinent medical devices to include in these national materials. These then underwent internal and external review. A provider course for biomedical engineers and technicians was introduced. Skills labs were established to improve practical skills teaching. To improve the quality of teaching, a NEST360 generic instructors course (GIC) was developed. RESULTS Twenty modules, 14 scenarios, 17 job aids and 34 videos have been published to date. Materials have been embedded into neonatal curricula and national trainings. Forty-one skills labs were installed in pre-service learning institutions and, up to June 2022, have been used by 7281 students. Pre- and in-service interprofessional training was implemented at all NEST360 institutions (clinical and biomedical). GIC courses were conducted at least twice a year in all countries. Three hundred seventeen nurses, biomedical and clinical staff have undertaken the GIC in all four countries. GIC participants report that the course has very positively influenced their teaching practice. CONCLUSIONS Inclusion of key stakeholders throughout has ensured training is embedded within the four countries. Use of interprofessional education and inclusion of biomedical engineers and technicians has been very successful. Introduction of the GIC has developed a pool of high-quality educators for neonatal care. This approach has ensured that high-quality interprofessional neonatal training is included within national agendas for neonatal care and beyond.
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Affiliation(s)
- Josephine Langton
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi.
| | | | - Edith Gicheha
- Rice360 Institute for Global Health Technologies, Rice University, Houston, TX, USA
| | | | | | - George Banda
- NEST360, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Elizabeth M Molyneux
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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de Visser MA, Kululanga D, Chikumbanje SS, Thomson E, Kapalamula T, Borgstein ES, Langton J, Kadzamira P, Njirammadzi J, van Woensel JBM, Bentsen G, Weir PM, Calis JCJ. Outcome in Children Admitted to the First PICU in Malawi. Pediatr Crit Care Med 2023; 24:473-483. [PMID: 36856446 PMCID: PMC10226467 DOI: 10.1097/pcc.0000000000003210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVES Dedicated PICUs are slowly starting to emerge in sub-Saharan Africa. Establishing these units can be challenging as there is little data from this region to inform which populations and approaches should be prioritized. This study describes the characteristics and outcome of patients admitted to the first PICU in Malawi, with the aim to identify factors associated with increased mortality. DESIGN Review of a prospectively constructed PICU database. Univariate analysis was used to assess associations between demographic, clinical and laboratory factors, and mortality. Univariate associations ( p < 0.1) for mortality were entered in two multivariable models. SETTING A recently opened PICU in a public tertiary government hospital in Blantyre, Malawi. PATIENTS Children admitted to PICU between August 1, 2017, and July 31, 2019. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Of 531 included PICU admissions, 149 children died (28.1%). Mortality was higher in neonates (88/167; 52.7%) than older children (61/364; 16.8%; p ≤ 0.001). On univariate analysis, gastroschisis, trachea-esophageal fistula, and sepsis had higher PICU mortality, while Wilms tumor, other neoplasms, vocal cord papilloma, and foreign body aspiration had higher survival rates compared with other conditions. On multivariable analysis, neonatal age (adjusted odds ratio [AOR], 4.0; 95% CI, 2.0-8.3), decreased mental state (AOR, 5.8; 95 CI, 2.4-13.8), post-cardiac arrest (AOR, 2.0; 95% CI, 1.0-8.0), severe hypotension (AOR, 6.3; 95% CI, 2.0-19.1), lactate greater than 5 mmol/L (AOR, 4.2; 95% CI, 1.5-11.2), pH less than 7.2 (AOR, 3.1; 95% CI, 1.2-8.0), and platelets less than 150 × 10 9 /L (AOR, 2.4; 95% CI, 1.1-5.2) were associated with increased mortality. CONCLUSIONS In the first PICU in Malawi, mortality was relatively high, especially in neonates. Surgical neonates and septic patients were identified as highly vulnerable, which stresses the importance of improvement of PICU care bundles for these groups. Several clinical and laboratory variables were associated with mortality in older children. In neonates, severe hypotension was the only clinical variable associated with increased mortality besides blood gas parameters. This stresses the importance of basic laboratory tests, especially in neonates. These data contribute to evidence-based approaches establishing and improving future PICUs in sub-Saharan Africa.
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Affiliation(s)
- Mirjam A de Visser
- Department of Pediatric Intensive Care, Emma Children's Hospital of the Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Diana Kululanga
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Singatiya S Chikumbanje
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Anesthesiology and Intensive Care, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Emma Thomson
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Surgery, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tiyamike Kapalamula
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Surgery, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Eric S Borgstein
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Surgery, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Josephine Langton
- Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Precious Kadzamira
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Anesthesiology and Intensive Care, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jenala Njirammadzi
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital of the Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Gunnar Bentsen
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Patricia M Weir
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Job C J Calis
- Department of Pediatric Intensive Care, Emma Children's Hospital of the Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Mercy James Center for Pediatric Surgery and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital & Kamuzu University of Health Sciences, Blantyre, Malawi
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Lester R, Musicha P, Kawaza K, Langton J, Mango J, Mangochi H, Bakali W, Pearse O, Mallewa J, Denis B, Bilima S, Gordon SB, Lalloo DG, Jewell CP, Feasey NA. Effect of resistance to third-generation cephalosporins on morbidity and mortality from bloodstream infections in Blantyre, Malawi: a prospective cohort study. Lancet Microbe 2022; 3:e922-e930. [PMID: 36335953 PMCID: PMC9712123 DOI: 10.1016/s2666-5247(22)00282-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The burden of antimicrobial resistance is a major threat to global health; however, prospective clinical outcome data from Africa are scarce. In Malawi, third-generation cephalosporins are the antibiotics of choice in patients admitted to hospital despite a rapid proliferation of resistance to these drugs. We aimed to quantify the effect of resistance to third-generation cephalosporins on mortality and length of hospital stay among patients with bloodstream infections. METHODS We did a prospective cohort study of patients admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi. Patients of all ages who had positive blood cultures for Enterobacterales were included, with the exception of those from the genus Salmonella, and were followed up for 180 days. We characterised blood culture isolates using whole-genome sequencing and used Cox regression models to estimate the effect of resistance to third-generation cephalosporins on length of hospital stay, in-hospital mortality, and survival. FINDINGS Between Jan 31, 2018, and Jan 13, 2020, we recruited 326 patients, from whom 220 (68%) of 326 isolates were resistant to third-generation cephalosporins. The case fatality proportion was 45% (99 of 220) in patients with bloodstream infections that were resistant to third-generation cephalosporins, and 34% (36 of 106) in patients with bloodstream infections that were sensitive to third-generation cephalosporins. Resistance to third-generation cephalosporins was associated with an increased probability of in-hospital mortality (hazard ratio [HR] 1·44, 95% CI 1·02-2·04), longer hospital stays (1·5 days, 1·0-2·0) and decreased probability of discharge alive (HR 0·31, 0·22-0·45). Whole-genome sequencing showed a high diversity of sequence types of both Escherichia coli and Klebsiella pneumoniae. Although isolates associated with death were distributed across clades, we identified three E coli clades (ST410, ST617, and ST648) that were isolated from 14 patients who all died. INTERPRETATION Resistance to third-generation cephalosporins is associated with increased mortality and longer hospital stays in patients with bloodstream infections in Malawi. These data show the urgent need for allocation of resources towards antimicrobial resistance mitigation strategies in Africa. FUNDING Wellcome Trust and Wellcome Asia and Africa Programme.
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Affiliation(s)
- Rebecca Lester
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Patrick Musicha
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Parasites and Microbes Programme, Wellcome Sanger Institute, Hinxton, UK
| | - Kondwani Kawaza
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - James Mango
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Helen Mangochi
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Winnie Bakali
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Oliver Pearse
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jane Mallewa
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Brigitte Denis
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sithembile Bilima
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Stephen B Gordon
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David G Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Christopher P Jewell
- Centre for Health Informatics, Computing and Statistics, Lancaster University, Lancaster, UK
| | - Nicholas A Feasey
- Malawi-Liverpool Wellcome Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Prins W, Stamatelou E, Dellimore K, Likumbo A, Kafulafula E, Langton J, Njirammadzi J, Mwenisungo J, Msukwa T, Calis J, van Sloun R, Bierling B. A U - Net Deep Learning Model for Infant Heart Rate Estimation from Ballistography . Annu Int Conf IEEE Eng Med Biol Soc 2022; 2022:1919-1922. [PMID: 36086528 DOI: 10.1109/embc48229.2022.9871797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Ballistography(BSG) is a non-intrusive and low- cost alternative to electrocardiography (ECG) for heart rate (HR) monitoring in infants. Due to the inter-patient variance and susceptibility to noise, heartbeat detection in the BSG waveform remains a challenge. The aim of this study was to estimate HR from a bed-based pressure mat BSG signal using a deep learning approach. We trained a U-Net deep neural network through supervised learning by deriving ground truth as the location of the heartbeats from simultaneously recorded ECG signals after peak matching. For improved generalization, we modified an existing U - Net to include an IC-layer. A predictive performance of 80% was achieved using the U-Net without the IC-layer. The inclusion of the IC-layer, while improving the generalization ability of the model to detect heartbeats, did not improve the HR estimation performance.
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King C, Zadutsa B, Banda L, Phiri E, McCollum ED, Langton J, Desmond N, Qazi SA, Nisar YB, Makwenda C, Hildenwall H. Prospective cohort study of referred Malawian children and their survival by hypoxaemia and hypoglycaemia status. Bull World Health Organ 2022; 100:302-314B. [PMID: 35521039 PMCID: PMC9047421 DOI: 10.2471/blt.21.287265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 02/08/2022] [Accepted: 02/08/2022] [Indexed: 01/13/2023] Open
Abstract
Objective To investigate survival in children referred from primary care in Malawi, with a focus on hypoglycaemia and hypoxaemia progression. Methods The study involved a prospective cohort of children aged 12 years or under referred from primary health-care facilities in Mchinji district, Malawi in 2019 and 2020. Peripheral blood oxygen saturation (SpO2) and blood glucose were measured at recruitment and on arrival at a subsequent health-care facility (i.e. four hospitals and 14 primary health-care facilities). Children were followed up 2 weeks after discharge or their last clinical visit. The primary study outcome was the case fatality ratio at 2 weeks. Associations between SpO2 and blood glucose levels and death were evaluated using Cox proportional hazards models and the treatment effect of hospitalization was assessed using propensity score matching. Findings Of 826 children recruited, 784 (94.9%) completed follow-up. At presentation, hypoxaemia was moderate (SpO2: 90-93%) in 13.1% (108/826) and severe (SpO2: < 90%) in 8.6% (71/826) and hypoglycaemia was moderate (blood glucose: 2.5-4.0 mmol/L) in 9.0% (74/826) and severe (blood glucose: < 2.5 mmol/L) in 2.3% (19/826). The case fatality ratio was 3.7% (29/784) overall but 26.3% (5/19) in severely hypoglycaemic children and 12.7% (9/71) in severely hypoxaemic children. Neither moderate hypoglycaemia nor moderate hypoxaemia was associated with mortality. Conclusion Presumptive pre-referral glucose treatment and better management of hypoglycaemia could reduce the high case fatality ratio observed in children with severe hypoglycaemia. The morbidity and mortality burden of severe hypoxaemia was high; ways of improving hypoxaemia identification and management are needed.
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Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institutet, Tomtebogatan 18a, Stockholm, 17177, Sweden
| | | | - Lumbani Banda
- Parent and Child Health Initiative, Lilongwe, Malawi
| | | | - Eric D McCollum
- Global Program in Respiratory Sciences, Johns Hopkins University, Baltimore, United States of America
| | | | - Nicola Desmond
- Behaviour and Health Group, Malawi-Liverpool-Wellcome Trust Programme, Blantyre, Malawi
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | | | - Helena Hildenwall
- Department of Global Public Health, Karolinska Institutet, Tomtebogatan 18a, Stockholm, 17177, Sweden
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9
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Thunberg A, Zadutsa B, Phiri E, King C, Langton J, Banda L, Makwenda C, Hildenwall H. Hypoxemia, hypoglycemia and IMCI danger signs in pediatric outpatients in Malawi. PLOS Glob Public Health 2022; 2:e0000284. [PMID: 36962312 PMCID: PMC10021275 DOI: 10.1371/journal.pgph.0000284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/02/2022] [Indexed: 02/01/2023]
Abstract
Hypoxemia and hypoglycemia are known risks for mortality in children in low-income settings. Routine screening with pulse oximetry and blood glucose assessments for outpatients could assist in early identification of high-risk children. We assessed the prevalence of hypoglycemia and hypoxemia, and the overlap with Integrated Management of Childhood Illness (IMCI) general danger signs, among children seeking outpatient care in Malawi. A cross-sectional study was conducted at 14 government primary care facilities, four rural hospitals and one district referral hospital in Mchinji district, Malawi from August 2019-April 2020. All children aged 0-12 years seeking care with an acute illness were assessed on one day per month in each facility. Study research assistants measured oxygen saturation using Lifebox LB-01 pulse oximeter and blood glucose was assessed with AccuCheck Aviva glucometers. World Health Organization definitions were used for severe hypoglycemia (<2.5mmol/l) and hypoxemia (SpO2 <90%). Moderate hypoglycemia (2.5-4.0mmol/l) and hypoxemia (SpO2 90-93%) were also calculated and prevalence levels compared between those with and without IMCI danger signs using chi2 tests. In total 2,943 children were enrolled, with a median age of 41 (range: 0-144) months. The prevalence of severe hypoxemia was 0.6% and moderate hypoxemia 5.4%. Severe hypoglycemia was present in 0.1% of children and moderate hypoglycemia in 11.1%. IMCI general danger signs were present in 29.3% of children. All severely hypoglycemic children presented with an IMCI danger sign (p <0.001), but only 23.5% of the severely hypoxemic and 31.7% of the moderately hypoxemic children. We conclude that while the prevalence of severe hypoxemia and hypoglycemia were low, moderate levels were not uncommon and could potentially be useful as an objective tool to determine referral needs. IMCI danger signs identified hypoglycemic children, but results highlight the challenge to detect hypoxemia. Future studies should explore case management strategies for moderate hypoxemia and hypoglycemia.
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Affiliation(s)
- André Thunberg
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm Sweden
| | | | | | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Institute for Global Health, University College London, London, England
| | | | - Lumbani Banda
- Parent and Child Health Initiative, Lilongwe, Malawi
| | | | - Helena Hildenwall
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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10
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Ngwalangwa F, Katumbi C, Dube Q, Langton J, Baker T, Janson A, Hildenwall H. The Association of Low Blood Glucose and Low Serum Cortisol Levels in Severely Ill Children Admitted to Tertiary Referral Hospitals in Malawi: A Case-Control Study. Am J Trop Med Hyg 2021; 105:846-851. [PMID: 34280148 PMCID: PMC8592371 DOI: 10.4269/ajtmh.21-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/14/2021] [Indexed: 11/23/2022] Open
Abstract
Low blood glucose concentrations < 5 mmol/L in severely ill children presenting to hospitals in low-income countries are associated with mortality. Adrenal insufficiency with low cortisol levels may contribute to low blood glucose concentrations. Understanding the association between low cortisol and low blood glucose may assist in improving guidelines for management of severely ill children. The study aimed to determine the association between low serum cortisol and low blood glucose in severely ill children. A matched case-control study of children aged 1 month to 15 years was conducted at two tertiary hospitals in Malawi. Cases were children with blood glucose < 5 mmol/L. Two age-matched controls with blood glucose of ≥ 5–15 mmol/L were enrolled per case. Low cortisol was defined as serum cortisol of < 25 µg/dL (690 nmol/L) and adrenal insufficiency as serum cortisol of < 10 µg/dL (276 nmol/L). A total of 54 cases and 108 controls were enrolled with, median age of 2.8 years (interquartile range [IQR]: 1.7–4.4). The median cortisol level was 58.7 µg/dL (IQR: 42.3–61.8) in cases and 40.9 µg/dL (IQR: 33.7–51.2) in controls (P = 0.911). The proportion of low cortisol was 4/54 (7.4%) in cases and 9/108 (8.3%) in controls. Logistic regression shows no association between low cortisol and low blood glucose (adjusted odds ratio: 0.33; 95% confidence interval, 0.04–3.02). Results suggest that there is no association between low cortisol and low blood glucose among severely ill children presenting to hospitals in Malawi. The reason for low blood glucose needs further investigation.
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Affiliation(s)
- Fatsani Ngwalangwa
- Department of Paediatrics, University of Malawi, College of Medicine, Blantyre, Malawi.,Department of Public Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Clifford Katumbi
- Clinical Department, Light House Trust, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Queen Dube
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Tim Baker
- Department of Paediatrics, University of Malawi, College of Medicine, Blantyre, Malawi.,Karolinska Institutet, Department of Global Public Health, Stockholm, Sweden.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Annika Janson
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Karolinska Institutet, Department of Womeńs and Childreńs Health, Stockholm, Sweden
| | - Helena Hildenwall
- Karolinska Institutet, Department of Global Public Health, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Karolinska Institutet, Department of Clinical Science, Intervention and Technology, Huddinge, Sweden
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11
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Chaziya J, Freyne B, Lissauer S, Nielsen M, Langton J, O'Hare B, Molyneux L, Moxon C, Iroh Tam PY, Hoskyns L, Masanjala H, Ilepere S, Ngwira M, Kawaza K, Mumba D, Chimalizeni Y, Dube Q. COVID-19 in Malawi: lessons in pandemic preparedness from a tertiary children's hospital. Arch Dis Child 2021; 106:238-240. [PMID: 33361067 PMCID: PMC7768613 DOI: 10.1136/archdischild-2020-319980] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Jessica Chaziya
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi,Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bridget Freyne
- Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK .,Department of Paediatrics, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi
| | - Samantha Lissauer
- Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK,Department of Paediatrics, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi
| | - Maryke Nielsen
- Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi,Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | | - Liz Molyneux
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi,Department of Paediatrics, College of Medicine, Blantyre, Malawi
| | - Christopher Moxon
- Department of Paediatrics, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi,University of Glasgow, Glasgow, Glasgow, UK
| | - Pui-Ying Iroh Tam
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi,Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Lucy Hoskyns
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Henderson Masanjala
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Sakina Ilepere
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi,Kamuzu College of Nursing, Blantyre, Malawi
| | - Memory Ngwira
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi,Kamuzu College of Nursing, Blantyre, Malawi
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi,Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Daniel Mumba
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi,Kamuzu College of Nursing, Blantyre, Malawi
| | - Yamikani Chimalizeni
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi,Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Queen Dube
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi,Paediatric Department, Queen Elizabeth Central Hospital, Blantyre, Malawi
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12
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Muttalib F, Ballard E, Langton J, Malone S, Fonseca Y, Hansmann A, Remy K, Hovmand P, Doctor A. Application of systems dynamics and group model building to identify barriers and facilitators to acute care delivery in a resource limited setting. BMC Health Serv Res 2021; 21:26. [PMID: 33407458 PMCID: PMC7787401 DOI: 10.1186/s12913-020-06014-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi. Methods Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed. Results Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias. Conclusions GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting.
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Affiliation(s)
- Fiona Muttalib
- Centre for Global Child Health, Hospital for Sick Children, 555 University avenue, Toronto, ON, M5G 1X8, Canada.
| | - Ellis Ballard
- Social System Design Lab, Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | | | - Sara Malone
- Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | - Yudy Fonseca
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Andreas Hansmann
- Neonatal and Paediatric ICU, National Pediatric Hospital, Phnom Penh, Cambodia
| | - Kenneth Remy
- Departments of Pediatrics and Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Peter Hovmand
- Social System Design Lab, Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | - Allan Doctor
- Pediatric Critical Care Medicine and Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, USA
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13
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Kilov K, Hildenwall H, Dube A, Zadutsa B, Banda L, Langton J, Desmond N, Lufesi N, Makwenda C, King C. Integrated Management of Childhood Illnesses (IMCI): a mixed-methods study on implementation, knowledge and resource availability in Malawi. BMJ Paediatr Open 2021; 5:e001044. [PMID: 34013071 PMCID: PMC8098945 DOI: 10.1136/bmjpo-2021-001044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The introduction of the WHO's Integrated Management of Childhood Illnesses (IMCI) guidelines in the mid-1990s contributed to global reductions in under-five mortality. However, issues in quality of care have been reported. We aimed to determine resource availability and healthcare worker knowledge of IMCI guidelines in two districts in Malawi. METHODS We conducted a mixed-methods study, including health facility audits to record availability and functionality of essential IMCI equipment and availability of IMCI drugs, healthcare provider survey and focus group discussions (FGDs) with facility staff. The study was conducted between January and April 2019 in Mchinji (central region) and Zomba (southern region) districts. Quantitative data were described using proportions and χ2 tests; linear regression was conducted to explore factors associated with IMCI knowledge. Qualitative data were analysed using a pragmatic framework approach. Qualitative and quantitative data were analysed and presented separately. RESULTS Forty-seven health facilities and 531 healthcare workers were included. Lumefantrine-Artemether and cotrimoxazole were the most available drugs (98% and 96%); while amoxicillin tablets and salbutamol nebuliser solution were the least available (28% and 36%). Respiratory rate timers were the least available piece of equipment, with only 8 (17%) facilities having a functional device. The mean IMCI knowledge score was 3.96 out of 10, and there was a statistically significant association between knowledge and having received refresher training (coeff: 0.42; 95% CI 0.01 to 0.82). Four themes were identified in the FGDs: IMCI implementation and practice, barriers to IMCI, benefits of IMCI and sustainability. CONCLUSION We found key gaps in IMCI implementation; however, these were not homogenous across facilities, suggesting opportunities to learn from locally adapted IMCI best practices. Improving on-going mentorship, training and supervision should be explored to improve quality of care, and programming which moves away from vertical financing with short-term support, to a more holistic approach with embedded sustainability may address the balance of resources for different conditions.
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Affiliation(s)
- Kim Kilov
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Helena Hildenwall
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe, Malawi
| | | | - Lumbani Banda
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Josephine Langton
- Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi
| | - Nicola Desmond
- Malawi-Liverpool-Wellcome Trust Programme, Blantyre, Malawi
| | - Norman Lufesi
- Acute Respiratory Infections Unit, Ministry of Health, Lilongwe, Malawi
| | | | - Carina King
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden.,Institute for Global Health, University College London, London, UK
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14
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King C, Dube A, Zadutsa B, Banda L, Langton J, Desmond N, Lufesi N, Makwenda C, Hildenwall H. Paediatric Emergency Triage, Assessment and Treatment (ETAT) - preparedness for implementation at primary care facilities in Malawi. Glob Health Action 2021; 14:1989807. [PMID: 34779363 PMCID: PMC8592602 DOI: 10.1080/16549716.2021.1989807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The majority of deaths amongst children under 5 years are still due to preventable infectious causes. Emergency care has been identified as a key health system weakness, and referrals are often challenging. Objective We aimed to establish how prepared frontline facilities in Malawi are to implement WHO Emergency Triage Assessment and Treatment (ETAT) guidelines, to support policy and planning decisions. Methods We conducted a concurrent mixed-methods study, including facility audit; healthcare provider survey; focus group discussions (FGD) and semi-structured interviews with facility staff. The study was conducted in two districts in Malawi, Zomba and Mchinji, between January and May 2019. We included all frontline facilities, including dispensaries, primary health centres, rural and community hospitals. Quantitative data were described using proportions, means and linear regression. Qualitative data was analysed using a framework approach. Data were analysed separately and then triangulated into common themes. Results Forty-seven facilities and 531 healthcare providers were included in the audit and survey; 6 FGDs and 5 interviews were completed. Four common themes emerged: (1) current emergency case management; (2) referral practices; (3) trained staff capacity; (4) opportunities and barriers for ETAT. Triage was conducted in most facilities with various methods described, and 53% reporting all staff are responsible. Referrals were common, but challenging due to issues in transportation. Twelve percent of survey respondents had ETAT training, with clinical officers (41%) reporting this more frequently than other cadres. Training was associated with increased knowledge, independent of cadre. The main barriers to ETAT implementation were the lack of resources, but opportunities to improve quality of care were reported. Conclusions Malawian frontline facilities are already providing a level of emergency paediatric care, but issues in training, drug supplies and equipment were present. To effectively scale-up ETAT, policies need to include supply chain management, maintenance and strengthening referral communication.
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Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Institute for Global Health, University College London, London, UK
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (Meiru), Lilongwe, Malawi
| | | | - Lumbani Banda
- Parent and Child Health Initiative, Lilongwe, Malawi
| | | | - Nicola Desmond
- Department of International Public Health, Liverpool School of Tropical Medicine & Behaviour and Health Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyren, Malawi
| | - Norman Lufesi
- Acute Respiratory Infections Unit, Ministry of Health, Lilongwe, Malawi
| | | | - Helena Hildenwall
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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15
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Baker T, Ngwalangwa F, Masanjala H, Dube Q, Langton J, Marrone G, Hildenwall H. Effect on mortality of increasing the cutoff blood glucose concentration for initiating hypoglycaemia treatment in severely sick children aged 1 month to 5 years in Malawi (SugarFACT): a pragmatic, randomised controlled trial. Lancet Glob Health 2020; 8:e1546-e1554. [PMID: 33038950 DOI: 10.1016/s2214-109x(20)30388-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 07/03/2020] [Accepted: 08/14/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Low blood glucose concentrations are common in sick children who present to hospital in low-resource settings and are associated with increased mortality. The cutoff blood glucose concentration for the diagnosis and treatment of hypoglycaemia currently recommended by WHO (2·5 mmol/L) is not evidence-based. We aimed to assess whether increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely ill children at presentation to hospital improves mortality outcomes. METHODS We did a pragmatic, randomised controlled trial at two referral hospitals in Malawi. Severely ill children aged 1 month to 5 years presenting to the emergency department with a capillary blood glucose concentration of between 2·5 mmol/L (3·0 mmol/L in severely malnourished children) and 5·0 mmol/L were randomly assigned (1:1) by a computer-generated randomisation sequence, stratified by study site and severe malnutrition, to receive either an immediate intravenous bolus of 10% dextrose at 5 mL/kg followed by a 24-h maintenance infusion of 10% dextrose at 100 mL/kg for the first 10 kg of bodyweight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent kg of bodyweight (intervention group) or observation for a minimum of 60 min and standard care (control group). Participants and study personnel were not masked to treatment allocation. The primary outcome was all-cause in-hospital mortality, assessed on an intention-to-treat basis. Safety was also assessed in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT02989675. FINDINGS Between Dec 5, 2016, and Jan 22, 2019, 10 947 children were screened, of whom 332 were randomly assigned, and 322 were included in the final analysis (n=162 in the control group and n=160 in the intervention group). The study was terminated after an interim analysis at 24% enrolment indicated futility. The median age of participants was 2·3 years (IQR 1·4-3·2), 65 (45%) were female, and the baseline characteristics of participants were similar between the two groups. The number of in-hospital deaths from any cause was 26 (16%) in the control group and 24 (15%) in the intervention group, with an absolute mortality difference of 1·0% (95% CI -6·9 to 9·0). Serious adverse events, including hypoglycaemia, hyperglycaemia, convulsions, reduced consciousness, and death, were reported in 47 (29%) children in the control group and 39 (24%) children in the intervention group. INTERPRETATION Increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely sick children in Malawi from 2·5 mmol/L to 5·0 mmol/L did not reduce all-cause in-hospital mortality. Our findings do not support changing the cutoff for dextrose administration, and further research on the optimal management of severely ill children who present to the emergency department with low blood glucose concentrations is warranted. FUNDING Swedish Research Council and Stockholm Country Council.
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Affiliation(s)
- Tim Baker
- Health System and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Department of Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi; Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Fatsani Ngwalangwa
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Henderson Masanjala
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Queen Dube
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gaetano Marrone
- Health System and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Helena Hildenwall
- Health System and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi; Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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16
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Ngwalangwa F, Chirambo CM, Lindsjö C, Dube Q, Langton J, Baker T, Hildenwall H. Feeding practices and association of fasting and low or hypo glycaemia in severe paediatric illnesses in Malawi - a mixed method study. BMC Pediatr 2020; 20:423. [PMID: 32887575 PMCID: PMC7472578 DOI: 10.1186/s12887-020-02305-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The presence of low or hypo glycaemia in children upon admission to hospital in low income countries is a marker for poor outcome. Fasting during illness may contribute to low blood glucose and caretakers' feeding practices during childhood illnesses may thus play a role in the development of low or hypo glycaemia. This study aims to describe the caretaker's feeding practices and association of fasting with low or hypo glycaemia in sick children in Malawi. METHODS A mixed method approach was used combining quantitative cross-sectional data for children aged 0-17 years admitted to Queen Elizabeth Central Hospital (QECH), a tertiary hospital in Malawi, with qualitative focus group discussions conducted with caretakers of young children who were previously referred to QECH from the five health centres around QECH. Logistic regression was used to analyse the quantitative data and thematic content analysis was conducted for qualitative data analysis. RESULTS Data for 5131 children who were admitted through the hospital's Paediatric Accident and Emergency Department (A&E) were analysed whereof 2.1% presented with hypoglycaemia (< 2.5 mmol/l) and 6.6% with low glycaemia (≥2.5mmoll/l - < 5 mmol/l). Fasting for more than eight hours was associated with low glycaemia as well as hypoglycaemia with Adjusted Odds Ratios (AOR) of 2.9 (95% Confidence Interval (CI) of 2.3-3.7) and 4.6, (95% CI 3.0-7.0), respectively. Caretakers demonstrated awareness of the importance of feeding during childhood illness and reported intensified feeding attention to sick children but face feeding challenges when illness becomes severe causing them to seek care at a health facility. CONCLUSION Results suggests that caretakers understand the importance of feeding during illness and make efforts to intensify feeding a sick child but challenges occur when illness is severe leading to fasting. Fasting among children admitted to hospitals may serve as a marker of severe illness and determine those at risk of low and hypoglycaemia.
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Affiliation(s)
- Fatsani Ngwalangwa
- Department of Paediatrics, College of Medicine, University of Malawi, P/Bag 360, Blantyre, Malawi.
| | | | - Cecilia Lindsjö
- Department of Care Science, Malmö University, 205 06, Malmö, Sweden
| | - Queen Dube
- Department of Paediatrics, Queen Elizabeth Central Hospital, P.O Box 95, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, College of Medicine, University of Malawi, P/Bag 360, Blantyre, Malawi
| | - Tim Baker
- Department of Paediatrics, College of Medicine, University of Malawi, P/Bag 360, Blantyre, Malawi.,Department of Global Public Health, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Helena Hildenwall
- Department of Global Public Health, Karolinska Institutet, 171 77, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52, Huddinge, Sweden
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17
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Abstract
OBJECTIVES To evaluate associations with neonatal hypothermia in a tertiary-level neonatal unit (NU) in Malawi. METHODS Neonates with a birth weight >1000 g were recruited and temperatures were recorded 5 min after birth, on admission and 4 h thereafter. Clinical course and outcome were reviewed. Data were analysed using Stata v.15 and p < 0.05 was considered statistically significant. RESULTS Between August 2018 to March 2019, 120 neonates were enrolled, and 112 were included in the data analysis. Hypothermia at 5 min after birth was noted in 74%, 77% on admission to the NU and 38% at 24 h. Neonates who had hypothermia 5 min after birth were more likely to have hypothermia on admission to the NU compared with normothermic subjects (p < 0.01). All neonates with hypothermia on admission to the NU died (100 vs.72%, p = 0.02), but hypothermia at 5 min nor at 24 h were not associated with mortality. After adjusting for potential confounders, the odds ratio of hypothermia at 5 min for hypothermia on admission to NU was 13.31 (95% CI 4.17-42.54). DISCUSSION A large proportion of hospitalized neonates is hypothermic on admission and has associated morbidity and mortality. Our findings suggest that a strong predictor of mortality is neonatal hypothermia on admission to the NU, and that early intervention in the immediate period after delivery could decrease the incidence of hypothermia and reduce associated morbidity and mortality.
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Affiliation(s)
- Frank Phoya
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi,Department of Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi,Department of Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi
| | - Queen Dube
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi,Department of Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi
| | - Pui-Ying Iroh Tam
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi,Department of Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi,Paediatrics and Child Health Research Group, Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK,Correspondence: Pui-Ying Iroh Tam, Malawi-Liverpool Wellcome Trust Clinical Research Programme, P. O. Box 30096, Chichiri, Blantyre, Malawi. E-mail <>
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Ngwalangwa F, Phiri CHA, Dube Q, Langton J, Hildenwall H, Baker T. Risk Factors for Mortality in Severely Ill Children Admitted to a Tertiary Referral Hospital in Malawi. Am J Trop Med Hyg 2020; 101:670-675. [PMID: 31287044 PMCID: PMC6726928 DOI: 10.4269/ajtmh.19-0127] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In low-resource settings, many children are severely ill at arrival to hospital. The risk factors for mortality among such ill children are not well-known. Understanding which of these patients are at the highest risk could assist in the allocation of limited resources to where they are most needed. A cohort study of severely ill children treated in the resuscitation room of the pediatric emergency department at Queen Elizabeth Central Hospital in Malawi was conducted over a 6-month period in 2017. Data on signs and symptoms, vital signs, blood glucose levels, and nutritional status were collected and linked with in-hospital mortality data. The factors associated with in-hospital mortality were analyzed using multivariable logistic regression. Data for 1,359 patients were analyzed and 118 (8.7%) patients died. The following factors were associated with mortality: presence of any severely deranged vital sign, unadjusted odds ratio (UOR) 2.6 (95% CI 1.7–4.0) and adjusted odds ratio (AOR) 3.2 (95% CI 2.0–5.0); severe dehydration, UOR 2.6 (1.4–5.1) and AOR 2.8 (1.3–6.0); hypoglycemia glycemia (< 5 mmol/L), UOR 3.6 (2.2–5.8) and AOR 2.7 (1.6–4.7); and severe acute malnutrition, UOR 5.8 (3.5–9.6) and AOR 5.7 (3.3–10.0). This study suggests that among severely sick children, increased attention should be given to those with hypo/low glycemia, deranged vital signs, malnutrition, and severe dehydration to avert mortality among these high-risk patients.
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Affiliation(s)
- Fatsani Ngwalangwa
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Queen Dube
- Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Helena Hildenwall
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Public Health Sciences, Karolinska Institutet, Global Health-Health System and Policy Research Group, Stockholm, Sweden
| | - Tim Baker
- Department of Public Health Sciences, Karolinska Institutet, Global Health-Health System and Policy Research Group, Stockholm, Sweden.,Queen Elizabeth Central Hospital, Blantyre, Malawi.,Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
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19
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Whittle E, James E, Smith A, Highton M, Shaikh S, Stone B, Thompson J, Orr T, Hogan I, Stokes S, Langton J, Chu C, Orr T, Hogan I. 44 Wirral's Teletriage Service. Age Ageing 2020. [DOI: 10.1093/ageing/afz185.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
The Wirral Teletriage Service provides non-urgent clinical support to Wirral Care Homes in order to help avoid unnecessary hospital admissions for their residents. It also aims to provide quicker access to clinical assessment than via NHS 111 and to provide this care in the patient’s residence wherever possible.
Methods
Care homes call the Teletriage service when they have concerns about the health of one of their residents. The Teletriage nurse undertakes a clinical assessment of the resident remotely via Skype. Care Homes have been provided with a secure NHS email address to facilitate secure sharing of data. They have also been provided with iPads and training for their staff. After being assessed by Teletriage, residents are signposted to the most appropriate care pathway for their needs.
Results
76 Care Homes have signed up to the service. On average, the Teletriage Service receives 300-400 calls a month. In an 18 month period, the number of calls to NHS 111 have reduced by 76%. Out of all the calls to Teletriage, 22% of patients were managed by the Teletriage team with no onward referral, 57% were managed via community services e.g GPs, Community Geriatricians, and 10% were referred to the ambulance service. Emergency Health Care Plans (EHCPs), Preferred Priorities of Care and EOL (End of Life) wishes are taken into account.
Conclusions
The Teletriage project has reduced the number of phone calls to NHS 111 and the ambulance service, and subsequently has reduced the number of patients conveyed to hospital by 12%. The Teletriage nurses work very closely with various community services as well as GPs, NWAS and Community Geriatricians. The ongoing training and education provided to the Care Home Staff means that overall there has been good engagement with the project from the majority of the Wirral Care Homes.
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Affiliation(s)
- E Whittle
- Wirral University Teaching Hospitals NHS Foundation Trust
| | - E James
- Wirral Community Health and Care NHS Foundation Trust
| | - A Smith
- Wirral Community Health and Care NHS Foundation Trust
| | - M Highton
- Wirral Community Health and Care NHS Foundation Trust
| | - S Shaikh
- Wirral Clinical Commissioning Group
| | - B Stone
- Wirral Clinical Commissioning Group
| | | | - T Orr
- Wirral Community Health and Care NHS Foundation Trust
| | - I Hogan
- Wirral Community Health and Care NHS Foundation Trust
| | - S Stokes
- Wirral Clinical Commissioning Group
| | - J Langton
- Wirral University Teaching Hospitals NHS Foundation Trust
| | - C Chu
- Wirral University Teaching Hospitals NHS Foundation Trust
| | - T Orr
- Wirral Community Health and Care NHS Foundation Trust
| | - I Hogan
- Wirral Community Health and Care NHS Foundation Trust
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20
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Harris C, Mills R, Seager E, Blackstock S, Hiwa T, Pumphrey J, Langton J, Kennedy N. Paediatric deaths in a tertiary government hospital setting, Malawi. Paediatr Int Child Health 2019; 39:240-248. [PMID: 30451103 DOI: 10.1080/20469047.2018.1536873] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Malawisuccessfully achieved Millennium Development Goal (MDG) four by decreasing the under-5 mortality rate by two-thirds in 2012. Despite this progress child mortality is still high and in 2013, the leading causes of death in under-5s were malaria, acute respiratory infections and HIV/AIDS. Aims: To determine the causes of inpatient child death including microbiological aetiologies in Malawi. Methods: A prospective, descriptive study was undertaken in Queen Elizabeth Central Hospital over 12 months in 2015/2016. Data was collected for every paediatric covering HIV and nutritional status, cause of death, and microbiology. Deaths of inborn neonates were excluded. Results: Of 13,827 admissions, there were 488 deaths, giving a mortality rate of 3.5%. One-third of deaths (168) occurred in the first 24 h of admission and 255 after 48 h Sixty-eight per cent of those who died (332) were under 5 years of age. The five leading causes of death were sepsis (102), lower respiratory tract infection (67), acute gastroenteritis with severe dehydration (51), malaria (37) and meningitis (34). The leading non-communicable cause of death was solid tumour (12). Of the 362 children with a known HIV status 134 (37.0%) were HIV-infected or HIV-exposed. Of the 429 children with a known nutrional status, 93 had evidence of severe acute malnutrition (SAM). Blood cultures were obtained from 252 children 51 (20.2%) grew pathogenic bacteria with Klebsiella pneumoniae, Escherichia coli and Staphylococcus aureus being the most common. Conclusion: Despite a significant reduction in paediatric inpatient mortality in Malawi, infectious diseases remain the predominant cause. Abbreviations: ART: anti-retroviral therapy; Child PIP: Child Healthcare Problem Identification Programme; CCF: congestive cardiac failure; CNS: central nervous system; CoNS: coagulase-negative staphylococci; CSF: cerebrospinal fluid; DNA pcr: deoxyribonucleic acid polymerase chain reaction; ETAT: emergency triage assessment and treatment; LMIC: low- and middle-income countries; MDG: Millennium Development Goals; MRI: magnetic resonance imaging; MRSA: methicillin-resistant Staphylococcus aureus; NAI: non-accidental injury; NTS: non-typhi salmonella; PJP: Pneumocystis jiroveci pneumonia; PSHD: presumed severe HIV disease; QECH: Queen Elizabeth Central Hospital; RHD: rheumatic heart disease; RTA: road traffic accident; TB: tuberculosis; TBM: tuberculous meningitis; WHO: World Health Organization; SAM: severe acute malnutrition.
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Affiliation(s)
- Caroline Harris
- Department of Paediatrics, Great North Children's Hospital , Newcastle-upon-Tyne , UK
| | - Rowena Mills
- Department of Paediatrics, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust , Birmingham , UK
| | - Ezgi Seager
- Department of Paediatrics, Sandwell Hospital, Sandwell and West Birmingham Hospitals NHS Trust , Birmingham , UK
| | - Sarah Blackstock
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation, Trust , London , UK
| | - Tamanda Hiwa
- Department of Paediatrics, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust , Brighton , UK
| | - James Pumphrey
- Department of Paediatrics, Queen Elizabeth Central Hospital , Blantyre , Malawi
| | - Josephine Langton
- Department of Paediatrics, Queen Elizabeth Central Hospital , Blantyre , Malawi
| | - Neil Kennedy
- Centre for Medical Education, Queen's University , Belfast , UK
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21
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Daniel A, Chatenga H, Chimera B, Mbale E, Chisala M, Borgstein E, Langton J, Gonzalez C, Bandsma R, Vresk L. Health Professionals' Perceptions of a Pediatric Nutrition Support Program Led by a Clinical Dietitian at a Low-resource Hospital Setting in Malawi (P12-028-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz035.p12-028-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
The first four dietitians graduated in Malawi in 2017, providing a new opportunity to build capacity to introduce nutrition support in an acute care setting. We designed and implemented a pediatric nutrition support program at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi including the hiring of a local dietitian in August 2018. Upon introducing this program, we aimed to qualitatively assess perceptions around the nutrition support program from the perspective of health professionals at QECH.
Methods
Qualitative interviews using a narrative research approach were undertaken to understand perceptions about the nutrition support program. Participants were selected through a purposive sampling approach across the eight wards within the nutrition support program at QECH. Interviews were held with nurses (n = 5) and clinicians and surgeons (n = 11) at QECH in November and December 2018. These interviews were audio-recorded before being transcribed and themes were then coded inductively using NVivo 11 software.
Results
All participants of the qualitative interviews emphasized the importance and impact of the nutrition support program in enhancing care of hospitalized children and therefore improving child outcomes such as tolerability of clinical interventions, decreased duration of stay, and reduced risk of hospital readmission. Other themes that arose were the receptiveness of guardians of children who received nutrition support, the importance of engaging other health professionals in nutrition support, and the need for prioritization of nutrition support by the Ministry of Health to sustain and scale up this type of program in Malawi.
Conclusions
Qualitative interviews with nurses, clinicians, and surgeons highlighted the value of nutrition support to improve quality of care in low-resource hospital settings. Integration of dietitians into the healthcare system in low- and middle-income countries like Malawi will require further advocacy around the potential for nutrition support to improve outcomes in vulnerable children.
Funding Sources
The introduction of the nutrition support program was funded by the Centre for Global Child Health Catalyst Grant from the Hospital for Sick Children.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Robert Bandsma
- Hospital for Sick Children, Canada & University of Toronto, Canada
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22
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Zimmer B, Gamble L, Foster R, Kennedy N, Mayer D, Bailey JB, Lemon J, Langton J. Assessment of the impact on paediatric rabies at Queen Elizabeth Central Hospital, Blantyre, Malawi, following a mass canine rabies vaccination programme. Int J Infect Dis 2019. [DOI: 10.1016/j.ijid.2018.11.165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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23
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Daniel AI, Chatenga H, Chimera B, Mbale E, Chisala M, Borgstein E, Langton J, Gonzalez C, Bandsma RHJ, Vresk L. The introduction of a paediatric nutrition support program led by a clinical dietitian at a low-resource hospital setting in Malawi. Glob Health Action 2019; 12:1656452. [PMID: 31512960 PMCID: PMC6746265 DOI: 10.1080/16549716.2019.1656452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/08/2019] [Indexed: 11/25/2022] Open
Abstract
In low- and middle-income countries, nutrition support strategies are often suboptimal or non-existent in hospital settings. This is further compounded by high rates of malnutrition in these countries. The first four dietitians graduated in Malawi in 2017 providing a new opportunity to build capacity to introduce nutrition support in an acute care setting. A paediatric nutrition support program was implemented at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi including the hiring of a local dietitian. This capacity building paper explains the development and introduction of the nutrition support program including a description of perceptions of health professionals at QECH working alongside the dietitian. In the first four months of the program at QECH, the dietitian provided nutrition support to 183 different patients across paediatric wards. Nutritional interventions predominantly included infant formula and breastmilk fortification, provision of therapeutic feeds orally or via nasogastric tubes, increased dietary protein intake for children identified to be at high risk, and nutritional counselling to caregivers. More complex nutritional interventions were also given such as the insertion of gastrostomy tubes to deliver nutrition directly to the stomach. Following the introduction of the program, qualitative interviews were done with health professionals at QECH including nurses (n = 5) and physicians (n = 11). All participants emphasized the importance and impact of the nutrition support program in enhancing the care of hospitalized children, therefore improving outcomes such as tolerability of clinical interventions, decreased duration of stay, and reduced risk of hospital readmission. In conclusion, there is a need for nutrition support provided by a dietitian for different paediatric patients which was corroborated by positive feedback from health professionals at QECH. Integration of dietitians into the healthcare system by respective Ministries of Health will require advocacy around the potential for nutrition support to strengthen the quality of care of vulnerable children. A Chichewa abstract for this paper is available in a supplementary file.
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Affiliation(s)
- Allison I. Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Humphrey Chatenga
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bernadette Chimera
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Emmie Mbale
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Mphatso Chisala
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Eric Borgstein
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Surgery, College of Medicine, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Carmen Gonzalez
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Robert H. J. Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Laura Vresk
- Department of Clinical Dietetics, Hospital for Sick Children, Toronto, Ontario, Canada
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Lindsjö C, Chirambo CM, Langton J, Dube Q, Baker T, Hildenwall H. 'We just dilute sugar and give' health workers' reports of management of paediatric hypoglycaemia in a referral hospital in Malawi. Glob Health Action 2018; 11:1491670. [PMID: 30014776 PMCID: PMC6052417 DOI: 10.1080/16549716.2018.1491670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: Acutely sick children in resource-constrained settings who present with hypoglycaemia have poor outcomes. Studies have questioned the current hypoglycaemia treatment cut-off level of 2.5 mmol/l. Improved knowledge about health workers’ attitudes towards and management of hypoglycaemia is needed to understand the potential effects of a raised cut-off level. Objective: This research explored health workers’ perceptions about managing acutely ill children with hypoglycaemia in a Malawian referral hospital. A secondary objective was to explore health workers’ opinions about a potential increase in the hypoglycaemia cut-off level. Methods: We used a qualitative design with semi-structured individual interviews performed with health workers in the Paediatric Accident and Emergency Unit at Queen Elizabeth Central Hospital, Malawi, in October 2016. Data were analysed using latent content analysis. Ethical approval was obtained from the University of Malawi, College of Medicine Research and Ethics Committee P.01/16/1852. Results: Four themes were formed that described the responses. The first, ‘Critical and difficult cases need easy treatment’, showed that health workers perceived hypoglycaemia as a severe condition that was easily manageable. The second, ‘Health system issues’, revealed challenges relating to staffing and resource availability. The third, ‘From parental reluctance to demand’, described a change in parents’ attitudes regarding intravenous treatments. The fourth, ‘Positive about the change but need more information’, exposed health workers’ concerns about potential risks of a raised cut-off level for hypoglycaemia treatment, as well as benefits for the patients. Conclusions: Health workers perceived hypoglycaemia as a severe condition that is easy to manage when the required equipment and supplies are available. Due to the common lack of test equipment and dextrose supplies, health workers have adopted alternative strategies to diagnose and manage hypoglycaemia. A change to the hypoglycaemia treatment cut-off level raised concerns about potential risks, but was also thought to be of benefit for some patients.
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Affiliation(s)
- Cecilia Lindsjö
- a Global Health - Health System and Policy Research Group, Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden.,c Astrid Lindgren Children's Hospital , Karolinska University Hospital , Stockholm , Sweden
| | | | - Josephine Langton
- b Department of Paediatrics , College of Medicine, University of Malawi , Blantyre , Malawi
| | - Queen Dube
- b Department of Paediatrics , College of Medicine, University of Malawi , Blantyre , Malawi
| | - Tim Baker
- a Global Health - Health System and Policy Research Group, Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden.,b Department of Paediatrics , College of Medicine, University of Malawi , Blantyre , Malawi
| | - Helena Hildenwall
- a Global Health - Health System and Policy Research Group, Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden.,b Department of Paediatrics , College of Medicine, University of Malawi , Blantyre , Malawi.,c Astrid Lindgren Children's Hospital , Karolinska University Hospital , Stockholm , Sweden
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25
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Affiliation(s)
- Barbara L Zimmer
- Queen Elizabeth Central Hospital, College of Medicine, Private Bag 360, Blantyre 3, Malawi.
| | - Luke Gamble
- Mission Rabies, Worldwide Veterinary Service, Cranborne, UK
| | - Dagmar Mayer
- Mission Rabies, Worldwide Veterinary Service, Cranborne, UK
| | - Rachel Foster
- Department of Infection and Tropical Medicine and Department of Acute Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Josephine Langton
- Queen Elizabeth Central Hospital, College of Medicine, Private Bag 360, Blantyre 3, Malawi
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Harawa PP, Mbale E, Mallewa M, Dube Q, Langton J, Njiram'madzi J, Kumwenda B, Bandsma R, Voskuijl W. Parasitic and parachute research in global health. Lancet Glob Health 2018; 6:e840. [PMID: 30012265 DOI: 10.1016/s2214-109x(18)30324-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/27/2018] [Indexed: 11/18/2022]
Affiliation(s)
| | - Emmie Mbale
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mac Mallewa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Ministry of Health, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | | | | | | | - Robert Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Wieger Voskuijl
- Department of Pediatrics, Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centre, 1105 AZ, Amsterdam, Netherlands.
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27
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Baker T, Dube Q, Langton J, Hildenwall H. Mortality impact of an increased blood glucose cut-off level for hypoglycaemia treatment in severely sick children in Malawi (SugarFACT trial): study protocol for a randomised controlled trial. Trials 2018; 19:33. [PMID: 29325595 PMCID: PMC5765642 DOI: 10.1186/s13063-017-2411-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 12/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mortality in children remains high in sub-Saharan African hospitals. While antimalarial drugs, antibiotics and other definitive treatments are well understood, the role of emergency care with supportive therapies, such as maintaining normal glucose and electrolyte balances, has been given limited attention. Hypoglycaemia is common in children admitted to hospital in low-income settings. The current definition of hypoglycaemia is a blood glucose level < 2.5 mmol/L in a well-nourished child. Outcomes for these children are poor, with a mortality rate of up to 42%. An increased mortality has also been reported among acutely ill children with low-glycaemia, defined as a blood glucose level of 2.5-5.0 mmol/L. The reason for increased mortality rates is not fully understood. This proposal is for a randomised controlled trial to determine the impact on mortality of a raised treatment cut-off level for paediatric hypoglycaemia. METHODS A total of 1266 severely ill children (age range = 1 month - 5 years) admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi with blood glucose in the range of 2.5-5.0 mmol/L will be randomised into intervention or control groups. The intervention group will be treated with an intravenous bolus of 10% dextrose 5 mL/kg followed by a dextrose infusion in addition to standard care while the control group will receive standard care only. Children will be followed until discharge from hospital or death. DISCUSSION The first patient was enrolled in December 2016 and the expected trial deadline is January 2019. This study is the first to evaluate the benefits of increased dextrose administration in children presenting to hospital with low-glycaemia. The findings will inform national and international policies and guidelines for the management of children with blood sugar abnormalities. TRIAL REGISTRATION ClinicalTrials.gov, NCT02989675 . Registered on 5 December 2016.
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Affiliation(s)
- Tim Baker
- Global Health - Health System and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden.,Department of Anaesthesia & Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi.,Perioperative Medicine and Intensive Care, Karolinska Univeristy Hospital, Stockholm, Sweden
| | - Queen Dube
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Helena Hildenwall
- Global Health - Health System and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden. .,Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi. .,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
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Molyneux EM, Langton J, Njiram'madzi J, Robertson AM. Setting up and running a paediatric emergency department in a hospital in Malawi: 15 years on. BMJ Paediatr Open 2017; 1:e000014. [PMID: 29637093 PMCID: PMC5842997 DOI: 10.1136/bmjpo-2017-000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/07/2017] [Accepted: 04/10/2017] [Indexed: 11/16/2022] Open
Abstract
Paediatric emergency care is not recognised as a specialty in many countries in Africa but is being practised increasingly. Setting up a paediatric emergency care unit takes time and often involves trial and error. Here we describe the start of the paediatric emergency department in Blantyre, Malawi, a low-income country and how it has continued to evolve over 15 years, in the hope that our experience will inform and assist others who are already developing their own emergency unit or wishing to do so.
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Affiliation(s)
- Elizabeth M Molyneux
- Paediatric Department, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Josephine Langton
- Paediatric Department, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Jenala Njiram'madzi
- Paediatric Department, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Ann M Robertson
- Emergency Department, Macclesfield Hospital, Macclesfield, UK
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Abstract
BACKGROUND Although pneumonia is a common cause of death in children in Malawi, healthcare staff frequently encounter patients or carers who refuse oxygen therapy. This qualitative study documents factors that influence acceptance or refusal of oxygen therapy for children in Malawi. METHODS Nine group interviews involving 86 participants were held in community and hospital settings in rural and urban Malawi. Eleven in-depth interviews of healthcare staff providing oxygen were held in a central hospital. Thematic analysis of transcripts of the audio recordings was carried out to identify recurring themes. RESULTS Similar ideas were identified in the group interviews and in-depth staff interviews. Past experiences of oxygen use (direct and indirect, positive and negative) had a strong influence on views of oxygen. A recurrent theme was fear of oxygen, often due to a perceived association between death and recent oxygen use. Fears were intensified by a lack of familiarity with equipment used to deliver oxygen, distrust of medical staff and concerns about cost of oxygen. CONCLUSIONS This study identifies reasons for refusal of oxygen therapy for children in a low-income country. Findings from the study suggest that training of healthcare staff to address fears of parents, and information, education and communication (IEC) approaches that improve public understanding of oxygen and provide positive examples of its use are likely to be helpful in improving uptake of oxygen therapy in Malawi.
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Affiliation(s)
- Anna Clare Stevenson
- Department of Acute Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | | | - Neil Kennedy
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
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Lawson T, Langton J. Training in Anaesthesia—The Essential Curriculum. Br J Anaesth 2010. [DOI: 10.1093/bja/aeq237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Crossingham G, Sice P, Roberts M, Gale T, Lam H, Anderson I, Carr A, Davies P, Langton J. Improving work place assessments in anaesthesia. Anaesthesia 2010. [DOI: 10.1111/j.1365-2044.2009.06184_9.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Narula P, Porter L, Langton J, Rao V, Davies P, Cummins C, Kirk J, Barrett T, Protheroe S. Gastrointestinal symptoms in children with type 1 diabetes screened for celiac disease. Pediatrics 2009; 124:e489-95. [PMID: 19706580 DOI: 10.1542/peds.2008-2434] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The association between celiac disease (CD) and type 1 diabetes mellitus (DM) is recognized. Most cases of CD in patients with DM are reported to be asymptomatic. OBJECTIVES The objectives of this study were to (1) compare and audit our practice with the published standards for screening for CD in children with DM, (2) characterize the children with DM and biopsy-confirmed CD, in terms of growth and gastrointestinal symptoms, and compare them with children with DM and negative celiac serology, and (3) document the effects of a gluten-free diet (GFD) after 1 year of gastrointestinal symptoms, growth, and insulin requirement. METHOD We performed a retrospective case-note review of 22 children with DM, positive celiac serology +/- biopsy-confirmed CD, and 50 children with DM and negative celiac serology. RESULTS Twenty-two children (3.9% of the total diabetic population) had positive celiac serology on screening, with 17 (3%) having biopsy-confirmed CD. Ninety-four percent of the children had standardized celiac serology testing. At diagnosis of CD, 13 of the 17 biopsy-positive children (76.4%) had > or =1 gastrointestinal symptom. The frequency of gastrointestinal symptoms in negative celiac serology diabetic children was 6% (3 of 50) (P < .0005). Symptoms resolved in all children after introduction of a GFD. A significant improvement in weight SD score (P = .008) and BMI SD score (P = .02) was noted in those compliant with a GFD after 1 year. CONCLUSIONS Children with DM and CD have a higher frequency of gastrointestinal symptoms than their diabetic peers with negative celiac serology and are not truly asymptomatic. Institution of a GFD has a positive effect on nutritional status and symptom resolution in the short-term.
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Affiliation(s)
- Priya Narula
- Department of Gastroenterology, Birmingham Children's Hospital, Birmingham, UK.
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Adams D, Sice P, Anderson I, Gale T, Lam H, Langton J, Davies P, Carr A. Validation of simulation for recruitment to training posts in anaesthesia. Anaesthesia 2009. [DOI: 10.1111/j.1365-2044.2009.05966_18.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Onyeka BA, Langton J. Urinary output during induced labour in normotensive women: a prospective pilot study. J OBSTET GYNAECOL 2004; 20:594-6. [PMID: 15512672 DOI: 10.1080/01443610020001413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
All fluid intake and urine output were monitored and measured in 103 consecutive women with normal blood pressure and without a history of pre-existing renal disease during induced labour for various indications. Epidural analgesia was administered in all these women and labour was augmented with oxytocin infusion. All urine specimens passed were tested for specific gravity. The temperature of the labour rooms was between 25 and 27 degrees C. Analysed results (from 50 women) shows that at a mean fluid intake of 75 ml/hour (standard deviation (SD) 21.84), oliguria (urine output <30 ml/hour) occurred in 42 (84%) of the women. There was a positive correlation between fluid intake and urinary output (r(2)=0.8515, P<0.0001). Urinary specific gravity was high (>1010) in all the specimens throughout the study. This study suggests that oliguria may be a common component of labour managed in this manner and its interpretation in pre-eclamptics in labour may be viewed in this context. Oliguria may therefore be a poor indicator of renal function or worsening pre-eclampsia during labour and its management needs to be limited to the severe and persistent variety to avoid renal complications. We believe from this study that relevant urine and blood biochemistry are better correlates of renal function in labour.
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Affiliation(s)
- B A Onyeka
- Delivery Suite, Whiston Hospital, Prescot, Merseyside, UK
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Affiliation(s)
- J Langton
- Obstetrics and Gynaecology Unit, Whiston Hospital, Merseyside, UK
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Onyeka BA, Langton J, Nwosu EC. Placental abruption following induction of labour with prostaglandin gel. J OBSTET GYNAECOL 1997; 17:55-6. [PMID: 15511768 DOI: 10.1080/01443619750114121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- B A Onyeka
- Maternity and Gynaecology Unit, Whiston Hospital, Prescot, Merseyside, UK
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Langton J. BOOK REVIEWS. Br J Anaesth 1991. [DOI: 10.1093/bja/66.2.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Readers of theYearbookmay readily ascertain from its register of research and bibliography that the energy applied to the urban history of Victorian England has not only been substantial but is far from expended. The attraction of huge amounts of raw material, both quantitative and literary, is difficult to resist. However, the challenge of seeking less solidly founded insights with the less abundant and more indirect sources of the eighteenth and early-nineteenth centuries has met with a far less enthusiastic response. In any case the sparseness of eighteenth-century sources is less stark than at first appears. Although by no means as reliable or as widely ramified in content as census data, Anglican parish registers offer considerable scope for anyone willful enough to resist the census honey pot. Particularly when supported by ancillary sources, such as maps and directories, they provide sufficient information for at least a tentative exploration of the beginning and unfolding of an urban process whose mature expression is revealed in the cornucopia of the middle-nineteenth century.
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Gee S, Duckworth D, Brunton TL, Moore N, West S, Langton J, Cripps H, Clarke WB, Bowlby A, Lockwood CB, Ormerod JA, Herringham WP, Tooth HH, Garrod AE, Calvert J, Champneys FH, Griffith WSA, Power D, Waring HJ, Eccles WM, Bailey RC, Harmer WD, Jessop WHH, Spicer TH, Cumberbatch AE. St. Bartholomew's Hospital. West J Med 1904. [DOI: 10.1136/bmj.1.2248.280-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gee S, Langton J, Duckworth D, Cripps H, Brunton TL, Clarke WB, Moore N, Bowlby A, West S, Lockwood CB, Ormerod JA, Power D, Herringham WP, Waring HJ, Tooth HH, Eccles WM, Garrod AE, Bailey RC, Calvert J, Jessop WHH, Champneys FH, Spicer TH, Griffith WSA, Cumberbatch AE. ST. BARTHOLOMEW'S HOSPITAL. West J Med 1903. [DOI: 10.1136/bmj.2.2242.1622-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Duckworth D, Langton J. Removal by Operation of a Gangrenous Appendix Vermiformis containing a Fæcal Concretion. Secondary Laparotomy through the Linea Alba for Suppurative Peritonitis. Recovery. J R Soc Med 1889; 72:433-9. [PMID: 20896757 DOI: 10.1177/095952878907200124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Langton J, Bowlby AA. A Case of Multiple Embolism of the Arteries of the Extremities followed by the Formation of Aneurisms. With Remarks on the Relations of Embolism to Aneurism. J R Soc Med 1887; 70:117-138.5. [PMID: 20896694 DOI: 10.1177/095952878707000108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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