Auswahl der wissenschaftlichen Literatur zum Thema „Patient monitoring – Malawi“

Adults admitted to hospital with critical illness are vulnerable and at high risk of morbidity and mortality, especially in sub-Saharan African settings where resources are severely limited. As life expectancy increases, patient demographics and healthcare needs are increasingly complex and require integrated approaches. Patient outcomes could be improved by increased critical care provision that standardises healthcare delivery, provides specialist staff and enhanced patient monitoring and facilitates some treatment modalities for organ support. In Malawi, we established a new high-dependency unit within Queen Elizabeth Central Hospital, a tertiary referral centre serving the country’s Southern region. This unit was designed in partnership with managers, clinicians, nurses and patients to address their needs. In this practice piece, we describe a participatory approach to design and implement a sustainable high-dependency unit for a low-income sub-Saharan African setting. This included: prospective agreement on remit, alignment with existing services, refurbishment of a dedicated physical space, recruitment and training of specialist nurses, development of context-sensitive clinical standard operating procedures, purchase of appropriate and durable equipment and creation of digital clinical information systems. As the global COVID-19 pandemic unfolded, we accelerated unit opening in anticipation of increased clinical requirement and describe how the high-dependency unit responded to this demand.

ObjectiveEvaluate a novel continuous temperature monitor in a low-resource neonatal ward.DesignWe developed a low-cost continuous neonatal temperature monitor (NTM) for use in low-resource settings. Accuracy of NTM was initially assessed in the laboratory. Clinical evaluation then was performed in a neonatal ward in a central hospital in Malawi; eligible neonates (<1 week of age) were recruited for continuous temperature monitoring with NTM and a Philips Intellivue MP30 Patient Monitor.Interventions and outcome measuresThe temperature probes of NTM and the reference patient monitor were attached to the infant’s abdomen, and core temperature was continuously recorded for up to 3 hours. Axillary temperatures were taken every hour. We compared temperatures measured using NTM, the patient monitor and the axillary thermometer.ResultsLaboratory temperature measurements obtained with NTM were within 0.059°C (range: −0.035°C to 0.195°C) of a reference thermometer. A total of 39 patients were recruited to participate in the clinical evaluation of NTM; data from four patients were excluded due to faulty hardware connections. The mean difference in measured temperatures between the NTM and the Intellivue MP30 was −0.04°C (95% CI −0.52°C to 0.44°C).ConclusionNTM meets ISO 80601-2-56 standards for accuracy and is an appropriate, low-cost continuous temperature monitor for neonatal wards in low-resource settings.Trial registration numbersNCT03965312 and NCT03866122.

While an estimated 45% of pregnant women in Malawi are anaemic, only 33% take iron tablets for a minimum of 90 days during pregnancy. The study explored the capacity of health facilities and communities to strengthen antenatal iron folate supplementation in Ntchisi, to support the achievement of Malawi’s nutrition target on halving anaemia in women of reproductive age by 2025. This qualitative study employed systematic random and purposeful sampling. Eight Focus Group Discussions with mothers of children 0-23 months, eight with Care Group volunteers and eight in-depth interviews with Village Health Workers (Health Surveillance Assistants) were conducted in each village falling within the catchment area of each of 8 health facilities. Health facilities had been sampled each from the 7 Traditional Authorities with the district hospital and direct observations had been conducted at each for antenatal care service delivery. 10 key informants from the health facilities and the District Health Office were interviewed. Thus a total of 16 FGDs, 8 HSA interviews, and 10 key informant interviews provided the data analysed in this paper. Data were analysed manually using thematic framework analysis. Poor access to and follow up of antenatal care at the health facility has limited access to iron folate supplements, as the health facility is the main source of Iron folates. Recurrent depletion of stock of iron folate were reported by mothers at most health facilities. Consumer demand for the tablets was low due to side effects, poor acceptability, associated myths, forgetfulness and frustration from having to take a daily medication. There was limited training and education materials at the health facility and community with inadequate support given to women. The absence of clear policies and guidelines on iron folate supplementation resulted in inconsistencies in messaging. Uptake and adherence were not routinely monitored. There is a need to improve the main building blocks of the iron folate programme, including the: delivery system, tablet supply, patient education, consumer demand, monitoring and evaluation and policy.

Most low-income nations have no practice guidelines for brain death; data describing brain death in these regions is absent. Our retrospective study describes the prevalence of brain death among patients treated in an intensive care unit (ICU) at a referral hospital in Malawi. The primary outcome was designation of brain death in the medical chart. Of 449 ICU patients included for analysis between September 2016 and May 2018, 43 (9.6%) were diagnosed with brain death during the ICU admission. The most common diagnostic reasons for admission among these patients were trauma (49%), malaria (16%) and postoperative monitoring after general abdominal surgery (19%). All patients diagnosed with brain death were declared dead in the hospital, after cardiac death. In conclusion, the incidence of brain death in a Malawi ICU is substantially higher than that seen in high-income ICU settings. Brain death is not treated as clinical death in Malawi.

Purpose Malawi is a low-income country in sub-Saharan Africa with limited health care infrastructure and high prevalance of HIV and tuberculosis. This study aims to determine the characteristics of patients presenting to Queen Elizabeth Central Hospital Oncology Unit, Blantyre, Malawi, who had been treated for tuberculosis before they were diagnosed with cancer. Methods Clinical data on all patients presenting to the oncology unit at Queen Elizabeth Central Hospital from 2010 to 2014 after a prior diagnosis of tuberculosis were prospectively recorded, and a descriptive analysis was undertaken. Results Thirty-four patients who had been treated for tuberculosis before being diagnosed with cancer were identified between 2010 and 2014, which represents approximately 1% of new referrals to the oncology unit. Forty-one percent of patients were HIV positive. Mean duration of tuberculosis treatment before presentation to the oncology unit was 3.6 months. The most common clinical presentation was a neck mass or generalized lymphadenopathy. Lymphoma was the most common malignancy that was subsequently diagnosed in 23 patients. Conclusion Misdiagnosis of cancer as tuberculosis is a significant clinical problem in Malawi. This study underlines the importance of closely monitoring the response to tuberculosis treatment, being aware of the possibility of a cancer diagnosis, and seeking a biopsy early if cancer is suspected.

Tenofovir-based antiretroviral therapy (TDF ART) is the first-line regimen for human immunodeficiency virus (HIV) in Africa. However, contemporary data on nephrotoxicity are lacking. We determined the renal outcomes of patients commenced on TDF ART in Malawi. ART-naïve patients initiated on TDF ART at a community health centre between 1 July 2013 and 31 December 2015 were included. The estimated glomerular filtration rate (eGFR, Cockcroft-Gault) was recorded at the initiation of therapy and over 18 months thereafter. The prevalence of renal impairment at ART initiation (eGFR < 60 ml/min) and the incidence of nephrotoxicity (eGFR < 50 ml/min) were determined. A total of 439 patients (median age: 32 years; 317 [72.2%] female) were included. Twenty-one (4.8%) patients had renal impairment at ART initiation; eGFR improved in all during follow-up. Nephrotoxicity occurred in 17 (4.0%) patients with eGFR > 50 ml/min at baseline, predominantly within the first six months of therapy. Increasing age and diastolic hypertension (>100 mmHg) were independent risk factors for nephrotoxicity development. The prevalence of kidney disease at ART initiation was 4.8% and nephrotoxicity occurred in 4.0%. Some eGFR decline may have been due to weight gain. Targeted monitoring of kidney function six months after TDF initiation should be considered in Malawi.

Scaling up of counselling and HIV testing (VCT) services requires a system of regular monitoring and evaluation. A VCT monitoring tool was developed through a consultative process and used to assess counselling and HIV testing services in 16 government and mission hospitals in Malawi, which had started expanded HIV-TB activities in July 2003. The essential components of the VCT monitoring tool included assessments of: (i) the hospital VCT personnel, in particular the number of counsellors (full-time and part-time) and those trained in and performing whole blood rapid HIV testing; (ii) the hospital laboratory service, in particular the protocols for HIV testing; (iii) the number, structure and function of dedicated VCT rooms; (iv) registers for patients, clients and donors having HIV tests; and (v) the quality of VCT through structured interviews with HIV-positive patients withTB. The main findings were: 9644 patients and clients were HIV tested between July and September 2003; HIV testing protocols were not standardized and differed between hospitals; there was little in the way of external quality assurance and there were deficiencies in the counselling process. In each hospital, the mean time taken to obtain the data and complete the VCT monitoring tool was 3 h. The VCT monitoring tool is straightforward to use, and the data collected should help to improve standardization, quality and future planning of VCT services in the country.

Introduction Celiac disease (CD) is an enteropathy that requires a gluten-free diet (GFD), a restriction often generating nutritional imbalances Objective. to assess the nutritional status of a pediatric CD population. Population and methods. Among 84 CD patients recruited, 64 were retained (37 F/27M) and aged 1-<17 years old (1-<5 y (n=24), 5-<10 y (n=17), and 10-<17 y (n=23)). The anthropometric measurements, parents education level and profession were collected. Eating habits, GFD quality, daily energy expenditure (DEE) were evaluated. Food consumption was estimated by a 24 hour recall, followed by a 3 day record. Results were compared to the recommended intakes (RI). Results. Nine % of 1-<5 y CD were thin, and 19% were overweight/obese. Significant improvement of body mass index (BMI) z-score was noted in CD girls (p<0.0001), and boys (p<0.01), after GFD. Non-existent breakfast was noted in 23% of children and 22% of adolescents. Sugary drinks consumption was observed in 38% of 1-<5 y infants, and snacking was found in 79% of them, as well as, in half of 5-<10 y, and 10-<17 y population. Twenty six % of adolescents had GFD voluntary deviations. Energy balance (total energy intake (TEI) - DEE) was positive in 5-<10 y, and negative in 10-<17 y. In all CD population, breakfast energy intake was lower than RI, but was important for snack time, also during morning snack in 1-<5 y and 5-<10 y infants. Simple carbohydrates and saturated fatty acids intakes were higher than RI, and iron and vitamin (Vit.) D deficiency was noted in CD population. Adolescents had low calcium and zinc intakes. Conclusion. The studied CD pediatric population presents some nutritional imbalances, requiring a dietary monitoring.

Over the past 30 years, information technology has gradually transformed the way health care is provisioned for patients. Chronic Obstructive Pulmonary Disease (COPD) is an incurable malady that threatens the lives of millions around the world. The huge amount of medical information in terms of complex interdependence between progression of health problems and various other factors makes the representation of data more challenging. This study investigated how formal semantic standards could be used for building an ontology knowledge repository to provide ubiquitous healthcare and medical recommendations for COPD patient to reduce preventable harm. The novel contribution of the suggested framework resides in the patient-centered monitoring approach, as we work to create dynamic adaptive protection services according to the current context of patient. This work executes a sequential modular approach consisting of patient, disease, location, devices, activities, environment and services to deliver personalized real-time medical care for COPD patients. The main benefits of this project are: (1) adhering to dynamic safe boundaries for the vital signs, which may vary depending on multiple factors; (2) assessing environmental risk factors; and (3) evaluating the patient’s daily activities through scheduled events to avoid potentially dangerous situations. This solution implements an interrelated set of ontologies with a logical base of Semantic Web Rule Language (SWRL) rules derived from the medical guidelines and expert pneumologists to handle all contextual situations.

Patients who are critically ill get often admitted to intensive care units (ICUs). The majority of these patients require support with their breathing and are thus connected to a mechanical ventilator. One aspect to consider in the mechanically ventilated patient is endotracheal tube cuff pressure (ETT) management. The management of ETT cuff pressure entails that nurses working in ICUs have the responsibility of ensuring that ETT cuff pressure is kept within normal range of 20-30 cmH20 for the safety of the patients in order to avoid complication of over and under inflation. Poor management of ETT cuff pressure places the mechanically ventilated patients under risk of tracheal injury. Tracheal injury may also be caused by over or under inflation of the ETT cuff. Over inflation of the ETT cuff can lead to the occlusion of capillaries lining the trachea at the cuff site, tracheal stenosis, and can also lead to the death of mucus membranes around the area, just to mention a few. On the other hand, under inflation of the ETT cuff, can lead to air leaks as well as aspiration of gastric contents into the tracheal tree. Therefore, in order to maintain ETT cuff pressure within normal ranges, evidence-based guidelines related to the management of ETT cuff pressure should be used. However, in Malawi the management of endotracheal tube cuff pressure in mechanically ventilated adult patients by nurses in ICUs is not well explored and it is not clear whether this practice is based on evidence-based guidelines. Furthermore, strategies on how to implement evidence-based guidelines in the ICU might not be known and poorly defined because of the complexity of the context. The study is therefore aimed at implementing and evaluating the effect of an evidence-based guideline on the management of ETT cuff pressure in mechanically ventilated adult patients by nurses in ICUs in Malawi using active (printed educational materials and monitoring visits) and passive (printed educational materials only) implementation strategies. The research study used a quantitative approach with multi-designs. Four phases were used in order to achieve the four objectives that were set. Phase one was the pre-test and used a survey design, two was the expert panel review of the evidence-based guideline, three was the implementation of the reviewed evidence-based guideline using a randomised controlled trial design and phase four was the post-test which used a survey design. The RCT included 25 participants from the control and 27 from the intervention group. Each group had three ICUs of which one in each group was from a private hospital and the other were government. Data collection in phases one and four was by a hand delivered pre-and post-questionnaire. In phase two the expert panel members with experience in critical care used the AGREE II Instrument to review the evidence-based guideline that was implemented. In order to gather data during the monitoring visits, the researcher recorded field notes. The applications that were developed by the University statistician consultant using visual basic applications in excel were used to analyse data. Two different implementation strategies were used to implement the evidence-based guideline. The control group used passive implementation strategy which was printed educational materials thus the evidence-based guideline and algorithm. The intervention group used both active and passive implementation strategies which was the printed educational materials thus the evidence-based guideline and algorithm plus monitoring visits by the researcher. In order to establish the effect of the implemented evidence-based guideline on the nursing care practice for the management of endotracheal tube cuff pressure an evaluative posttest survey was conducted in phase four of the research study. The results revealed that the majority of participants had gaps in both groups regarding nursing care practice for the management of endotracheal tube cuff pressure for the mechanically ventilated adult patients in the pretest but improved in the posttest. In the control group 52% had very low knowledge score, 16% had low score, 28% average, and 4% high score while in the category of very high score there was nobody. However, in the posttest those in the very low score were only 44% while the percentage in the low score remained 16%. There was an improvement in the average scores in the posttest such that only 44% were in this category. There was no one in the high and very high score in the pretest. On the other hand, in the intervention group, 78% had a very low score, 9% low score, and 13% were in the category of average score, while in the high and very high score category there was zero percent in the pretest. However, there was also an improvement in the posttest such that only 44% a very low knowledge score. But 19% had a low score, there were 37% in the average category and no one was in the high and very high score. Statistical analysis revealed that the results were not significantly different between and within groups. Improvements were observed in the two groups regarding the scientific knowledge scores for the nursing care practices in the posttest. Upon qualitative analysis of the data from the open-ended question, two main themes emerged thus the need for documentation of endotracheal tube cuff and the process of implementation the evidence-based guidelines. Sub themes such as lack of documentation; no part of routine care and monitoring not done at all were identified under the main theme of the need for documentation of ETT cuff pressure. The Guideline itself need to be clear; implementation strategies; follow up; incentives; supervision; incentives; time factor; resources or equipment required for successful implementation; nurses buy-in critical for the implementation; training detrimental to EBP implementation; nurses attitude crucial to implementation of EBGs and knowledge of nurses for guideline essential for the implementation were the sub themes identified under the main theme of the process of implementing the evidence-based guideline. All appropriate ethical considerations such as principles of autonomy and self-determination, confidentiality and anonymity, voluntary participation, right to receive treatment, informed consent, were adhered to throughout the research study. The research study was unique in nature because it was the first of its kind in Malawi and it contributed to the awareness of the recommended practice for management of endotracheal tube cuff pressure in the ICUs in the country by implementing an evidence-based guideline. The unique contribution of the study is that it is a challenge to implement evidence-based guideline in poor and resource constraint countries like Malawi.

Le dé cit cognitif est une cause majeure de handicap de la personne âgée. Du fait de l’augmentation de la durée de vie, le nombre de personnes âgées qui pourraient béné cier d’une prise en charge spécialisée dans le but de ralentir leur perte fonctionnelle va croitre. En dépit de traitement validé qui stoppe le processus neurodégénératif, des interventions spéci ques peuvent en ralentir les manifestations. De nombreuses études expérimentales, neuroscienti ques et comportementales ont démontré la relation étroite entre cognition en motricité.Ce travail doctoral propose d’explorer si certaines caractéristiques de la marche sont des biomarqueurs non-invasifs d’un trouble cognitif et des chutes, et de mieux comprendre les relations entre la cognition et le contrôle de la marche. Le cadre théorique était l’hypothèse de la « Perte de Complexité ». Des analyses multivariées ont été appliquées aux critères de jugement dynamiques de marche en relation avec le statut cognitif-et-chute (Le Chapitre 1).Le Chapitre 2 est une revue systématique de la littérature. Nous avons recensé 20 études longitudinales de prédiction de trouble de la marche et de dé cit cognitif. La vitesse de marche était associée à la cognition, son ralentissement était un prédicteur de la perte cognitive. Cette revue a aussi mis en évidence la nécessité d’améliorer la mesure des phénomènes concernésL’objectif du Chapitre 3 était de déterminer ce qu’apportait l’évaluation cognitive (MMSE, mémoire et fonctions exécutives) et des paramètres dynamiques précis de la marche, au bilan habituel du risque de chute. La précision de la classi cation entre chuteurs et non- chuteurs a augmenté avec l’ajout de la cognition et des paramètres de marche de AUC=0.86 à AUC=0.93. La spéci cité du modèle de classi cation a, quant à elle, augmenté de 60% à 72% avec l’ajout des mesures cognitives, et de 72% à 80% avec l’ajout des paramètres dynamiques de la marche. Dans leur ensemble, ces résultats montrent l’intérêt d’une approche multidimensionnelle incluant l’évaluation des fonctions cognitives et de la marche, dans la prédiction du risque de chute chez la personne âgée.Le Chapitre 4 détermine les paramètres de marche les plus associés au déclin cognitif. La vitesse de marche, la régularité, la prévisibilité et la stabilité ont montré que les simples et doubles-tâches étaient les plus discriminantes (score VIP moyen de 1.12). La marche des patients avec troubles cognitifs est plus lente, moins régulière et moins stable que celle de personnes âgées saines. Cependant, les résultats montrent également que la discrimination des patients âgés avec et sans dé cit cognitif, fondée sur l’exploitation des paramètres de marche uniquement, est faible, avec 57% (simple tâche) et 64% (double-tâche) des patients classés de manière erronée.Le Chapitre 5 présente une étude pilote prospective dans laquelle les paramètres de marche les plus discriminants du Chapitre 4 ont été étudiés. Les résultats ont montré qu’un déclin cognitif signi catif observé après 14.4 mois en moyenne était corrélé avec une marche plus régulière (ρ=0.579*) et plus prévisible (ρ=0.486*) mesurée pendent les mesures de ligne de base, mais pas avec la vitesse de marche de la ligne de base (ρ=0.073). Une augmentationde la régularité et de la prévisibilité de la marche est le re et d’une perte de la complexité de la marche, témoin d’une détérioration future des fonctions cognitives chez les patients âgés.Les résultats de ce travail doctoral sont résumés et discutés dans le Chapitre 6
The rising life expectancy will result in an increased number of ‘older old adults’ who will need specialized geriatric care to slow functional decline. Cognitive impairment is a major cause of disability in geriatric patients. Even though there is no cure yet to reverse neurodegeneration, tailored interventions can slow disease progression and reduce symptoms. Because of the abundant evidence from experimental, neuroscienti c, and behavioral studies that underscored the close link between motor- and cognitive function, the present thesis proposed to use gait characteristics as non-invasive indicators of cognitive impairment and falls in geriatric patients. The main objective therefore was to increase our understanding of the relationship between gait and cognition in this vulnerable population, in which gait outcomes were calculated from 3D-acceleration signals of the lower trunk that were collected with an iPod Touch 4G. The ‘Loss of Complexity’ hypothesis provided a theoretical framework. Multivariate analyses were applied to dynamic gait outcomes in relation to cognitive- and fall-status (Chapter 1).Chapter 2 presents a systematic literature review including 20 longitudinal studies that examined associations between baseline gait function and future cognitive decline. A slow gait speed was associated with future decline in global cognition and in speci c cognitive functions, and with an increased risk for Mild Cognitive Impairment (MCI) and dementia (maximal odds and hazard ratios of 10.4 and 11.1, respectively) in 4.5 years on average. The review projected that future research could increase the speci city of the gait-cognition link by indexing gait and cognition in more detail.From this perspective, Chapter 3 examined whether an extensive cognitive evaluation (global cognition, memory, and executive functioning) and ne-grained, dynamic gait outcomes could add to a usual fall-risk screening. The overall classi cation accuracy of fallers and non-fallers increased from Area Under the Curve (AUC) =0.86 to AUC=0.93. The speci city of the fall-classi cation model increased from 60% to 72% when cognitive outcomes were added, and from 72% up to 80% when gait dynamics were added to the model. The results underscored the need for a multifactorial approach in fall risk assessment in geriatric patients, including a detailed evaluation of cognitive- and gait function.Chapter 4 explored what gait outcomes are most susceptible to change with cognitive decline, and examined multiple gait outcomes in relation to cognitive impairment. Outcomes related to gait speed, regularity, predictability, and stability revealed with the highest discriminative power, indicated by the Variable Importance in Projection (VIP)-values for single- and dual-tasking (average VIP-score of 1.12, with a VIP-score>1 indicating a high discriminative power). Geriatric patients walked slower, less regular, and less stable than healthy old controls. However, the discrimination of geriatric patients with- and without cognitive impairment based on gait outcomes alone was poor, with 57% (single-task) and 64% (dual-task) of the patients being misclassi ed.In Chapter 5, the gait outcomes with the highest discriminative power in chapter 4 were studied in a prospective pilot study. Signi cant cognitive decline (in global cognition, memory, and executive functioning) over 14.4 months on average correlated with a moreregular (ρ=0.579*) and more predictable (ρ=0.486*) gait at baseline, but not with baseline gait speed (ρ=0.073). The increased gait regularity and predictability re ected a loss of gait complexity and this loss of gait complexity may thus predict future cognitive decline in geriatric patients.The results are summarized and discussed in Chapter 6 of this thesis

Non-invasive medical measurements have expanded into several types of diagnostic and monitoring activities in health care delivery. They are being used in handling a number of non-infectious diseases such as diabetes, asthma, hypertension, congestive heart failure, cardiac arrhythmia, etc., as well as infectious diseases such as cholera, malaria, etc.. Non-Invasive Medical Devices (NIMDs) are naturally preferred over invasive methods considering patient convenience, reduced patient risk, increased speed, and operational simplicity. However non-invasive methods are often perceived to be less accurate than their invasive counterparts. Over the last decade, technological advances and mathematical techniques have improved significantly, challenging this perception across the board. The chapter will discuss this important transformation in health care diagnostics and monitoring. The chapter will also provide further insight into some of the currently available non-invasive measurement products and explore how futuristic techniques and technology trends which have great potential to transform healthcare into a significantly different paradigm than the one we experience today.

Non-invasive medical measurements have expanded into several types of diagnostic and monitoring activities in health care delivery. They are being used in handling a number of non-infectious diseases such as diabetes, asthma, hypertension, congestive heart failure, cardiac arrhythmia, etc., as well as infectious diseases such as cholera, malaria, etc. Non-Invasive Medical Devices (NIMDs) are naturally preferred over invasive methods considering patient convenience, reduced patient risk, increased speed, and operational simplicity. However non-invasive methods are often perceived to be less accurate than their invasive counterparts. Over the last decade, technological advances and mathematical techniques have improved significantly, challenging this perception across the board. The chapter will discuss this important transformation in health care diagnostics and monitoring. The chapter will also provide further insight into some of the currently available non-invasive measurement products and explore how futuristic techniques and technology trends which have great potential to transform healthcare into a significantly different paradigm than the one we experience today.