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- ItemOpen AccessAetiology of stillbirths and adverse newborn outcomes at Queen Elizabeth central hospital, Blantyre, Malaw(2017-07-01) Chilinda, George KassimDeath of an infant in utero or at birth is a devastating experience for the mother and of concern in clinical practice. Developing countries struggle to provide comprehensive care to pregnant mothers and the new born. Stillbirths are common in poor countries that their occurrence is perceived inevitable. We aimed to characterize factors associated with stillbirth in our referral hospital population.Intrapartum birth asphyxia is a major contributor of high perinatal mortality in resource limited countries like Malawi. In low and middle income countries, about 59 % of the stillbirths are intrapartum unlike in developed countries where it is significantly lower than 10%. Studies done in Malawi have shown that birth asphyxia is a common cause of stillbirth. Furthermore, babies born with asphyxia may have increased long-term morbidity such as cerebral palsy, hence the need to identify new-borns at risk. The analysis of umbilical cord blood gases has been shown to be the gold standard for diagnosis of near-birth metabolic acidosis. Lactate has emerged as the preferred marker of acidosis in clinical practice. To determine the aetiology of stillbirths and adverse new-born outcomes among women delivering at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi This was a cross-section study done in two phases. In the first phase, data on all stillbirths that occurred at QECH between 1st August 2016 and 31st September 2016 was collected from the labour ward and Chatinkha operating theatre registries and patients’ files. All mothers of stillborn babies during the study period gave informed consent to participate in the study and have their blood samples collected and tested for VDRL, malaria, haemoglobin and fasting blood sugar on the bedside using point of care syphilis testing kit (Determine), malaria rapid diagnostic testing kit, Hemacue and glucometer respectively. The stillbirths were classified using the RECODE system The second phase was undertaken during April 2017. Data on all 401 births that occurred at QECH were collected from the labour ward and operating theatre registries and patients’ files. For all live births, umbilical arterial blood was drawn from a double clamped segment into heparinised plastic syringes. Lactate concentration in Umbilical cord arterial blood was analysed using Nova biomedical point of care devices within 15 minutes. All mothers had their blood samples collected and tested for VDRL, malaria, haemoglobin and fasting blood sugar at the bedside using point of care syphilis testing kit (Determine), malaria rapid diagnostic testing kit, Hemacue and glucometer respectively. During the first phase of the study, there were 54 stillbirths among 2149 deliveries translating to 25.1/1000births with 61% fresh stillbirths and 35% macerated stillbirth. 34% of the stillbirths were delivered through Caesarean section that was done after more than an hour from decision to undertake the procedure. Common relevant conditions at delivery were anaemia (52%), asphyxia (40%), hypertensive disorders (29%), placenta abruption ix (27%), HIV (25%) and syphilis (15%). None of the mothers had malaria or diabetes Mellitus. In phase two, the perinatal mortality was 44.9/1000births. The leading documented cause of nursery admission was birth asphyxia (41.7%). Shortage of theatre space accounted for all delays to do emergency Caesarean sections. Hyperlactatemia was associated with emergency caesarean sections, meconium stained liquor and vertex vaginal deliveries. There was no association between Hyperlactatemia and antepartum haemorrhage, gestational age, multiple gestation, PPROM, anaemia or malaria. Logistic regression modelling revealed that the odds of a composite adverse outcome (early neonatal death or admission to the neonatal unit) were significantly elevated in the presence of maternal hypertension (OR=2.9, P=0.019(95% C.I. 1.19-7.26)) after adjusting for the degree of hyperlactatemia. The study highlighted the risk factors for stillbirths at QECH. The risk factors for stillbirths at QECH include; preeclampsia, abruption placenta, anaemia, syphilis, and asphyxia. Poor intrapartum care attributed to lack of theatre capacity was the single most important cause of fresh stillbirths. None of the participating mothers had diabetes mellitus or malaria contrary to findings from other studies where both conditions were associated with increased risk of stillbirth. The ANC coverage was adequate, however, the quality of care provided in the centres needs improvement especially with regard to blood pressure testing and syphilis screening. Birth asphyxia is the most common cause of admission to the nursery and high perinatal mortality. The Apgar score at one minute is a good predictor of hyperlactatemia, however, x it over-diagnoses acidosis. Hypertensive mothers had 19% higher risk of having poor neonatal outcome for any given level of umbilical cord arterial lactate so additional attention to intrapartum and newborn monitoring for hypertensive mothers is required
- ItemOpen AccessAssociation of neonatal hypothermia with morbidity and mortality in a tertiary hospital in Malawi(Kamuzu University of Health Sciences, 2021-11-21) Phoya, FrankNeonatal hypothermia is a major risk factor for morbidity and mortality in the first 28 days of life. Studies conducted, in high resource setting have shown the impact of hyperthermia on morbidity and mortality in the first 28 days of life, which has lead to better implementation of prevent measures. In sub-Saharan Africa, very limited data on the effect of hyperthermia on morbidity and mortality is available. Due to lack of data, this has led to poorly implemented interventions and slow reduction in the neonatal mortality rate. This study aimed to document the level of neonatal morbidity and mortality, associated with neonatal hypothermia. It determined whether hypothermia at 5 minutes, on admission to the neonatal unit (NU), or at 24 hours, had the highest association with morbidity and mortality. This prospective observational study which was conducted at Queen Elizabeth Central Hospital, Blantyre Malawi recruited neonates with a birth weight greater than 1000 grams. Temperatures were recorded at birth, on admission and 4 hourly thereafter. Clinical course and outcome were reviewed. Data were analysed using Stata v.15 and p <0.05 was considered statistically significant. Between August 2018 to March 2019, 120 neonates were enrolled, of which 112 had complete data and were included in the data analysis. Hypothermia at 5 minutes after birth was noted in 74% (83), 77% (86) on admission to the NU and 38% (24/63) at 24 hours. Neonates who had hypothermia 5 minutes after birth were more likely to have hypothermia on admission to the NU compared to normothermic subjects (p<0.01). Hypothermia on admission to the NU was significantly associated with mortality (100% v.72%, p=0.02) but not hypothermia at 5 minutes nor at 24 hours. After adjusting for potential confounders, the odds ratio of Apgar scores <6 at 1 minute for mortality was 5.66 (95% CI 1.55-20.70) for neonates with hypothermia compared to normothermia, and of hypothermia at 5 minutes for hypothermia on admission to NU was 13.31 (95% CI 4.17-42.54. This study highlights the large proportion of hospitalized neonates who are hypothermic on admission and the association between neonatal hypothermia and poor outcome in terms of 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.
- ItemOpen AccessAn audit of antimicrobial treatment practices and laboratory diagnostics in febrile paediatric patients at Mzimba South District Hospital(2022-03-01) Manda, Happy, AbrahamBackground: It is a recommendation clinician to use Standard Treatment Guidelines (STG) to come up with presumptive diagnosis or order laboratory tests to support the diagnosis. Adherence to STG alone is a global concern. Objective: This study was to evaluate the antimicrobial prescribing practices among febrile paediatric patients in relation to Malawi Standard Treatment Guidelines (MSTG) and laboratory findings or usage at Mzimba South District Hospital (MSDH). Methods: This was a retrospective cross-sectional study using mixed methods where quantitative and qualitative methods were employed. Three hundred and sixty case notes for paediatric patients admitted to the children's ward from January to December 2017 were assessed. Findings: The common febrile illness diagnosed were malaria 194 (53.9%), sepsis 108(38.3%) and pneumonia 99(27.5%). The use of MSTG and laboratory investigations in prescribing was at 18.1% and 28.3% respectively. Despite the availability of MSTG and laboratory tests to guide antimicrobial prescribing practices, Amoxicillin was prescribed in 90%, Benzylpenicillin 85%, and Gentamicin 69% of febrile ill patients regardless of the malaria positive test results or the diagnosis. Artesunate and LA were prescribed in malaria negative patients in the final diagnosis of malaria at 49 (38.1%), sepsis 44 (40.7%) and pneumonia 19 (19.9 %). Conclusion: The laboratory tests and MSTG had minimal support to antimicrobial prescribing practices at MSDH. Prescribers prefer the use of empirical treatment with a focus on broad spectrums and if in dilemma consult the seniors. We recommend establishment of antimicrobial stewardships to monitor antimicrobial use and advocate on MSTG use. Furthermore, we recommend strengthening microbiology facilities to support identification of microbe and antimicrobial susceptibility.
- ItemOpen AccessAudit of maternal near misses at Queen Elizabeth central hospital, Chatinkha maternity unit(2017-07-01) Mvula, Priscilla Precious MwenechoMaternal near miss is an event in which a pregnant or recently delivered woman comes close to maternal death but does not die, due to either timely intervention or by pure chance. Evaluation of maternal near misses has been noted, in more developed countries, to aid in assessing the quality of obstetric care in a maternity unit and to formulate strategies to reduce the number of maternal deaths. It has been noted that up to 9 million women suffer from severe obstetric complications every year. This audit was done to determine the frequency of maternal near misses, to determine the proportion of near misses to maternal deaths, to assess the implementation of key evidence based interventions in women experiencing severe maternal morbidity. This was a prospective observational folder review where data was collected on standardized forms, from all admissions to the Chatinkha Maternity Unit at Queen Elizabeth Central Hospital between the months of July and December 2016. Data was entered into Epi Info and analyzed using Microsoft Excel and Epi Info. During this study period there were a total of 5463 deliveries in the unit, of which 5337 were live births. There were a total of 303 severe maternal complications. Using the WHO criteria, there were a total of 80(26.4%) near miss cases whilst 216(71.3%) fit the Haydom near misses criteria. There were 19 maternal deaths that occurred in the study vii period making a maternal mortality ratio of 356 per 100 000 live births. The leading cause of maternal near miss was obstetric haemorrhage (33.8%) followed by hypertensive disorders in pregnancy (32.9%), whilst pregnancy related infection (26.3%) was the commonest cause of maternal mortality. Maternal near misses are a common occurrence in our setting, and the main causes mirror those that cause maternal deaths. Obstetric haemorrhage and hypertensive disorders remains a big problem in our set up and there is need to be more diligent in preventing and treating these conditions.
- ItemOpen AccessCardiac disease in children with HIV-associated chronic lung disease at Queen Elizabeth Central Hospital, Blantyre, Malawi(Kamuzu University of Health Sciences, 2021-01-01) Mapurisa, Gugulethu NewtonOver the past decade, more perinatally-infected children have survived despite previous assertions that few would reach adolescence. More complications of the chronic human immunodeficiency virus (HIV) are surfacing with improving survival. These include HIV, chronic lung disease (HCLD), and cardiac disease (1-5). Such complications were previously associated with delayed diagnosis and poor HIV control. However, there is growing evidence that prolonged disease by itself predisposes to cardiac disease (6,7). Cardiac disease in HCLD has not been researched in children stable on ART. The study aimed to describe the cardiac symptoms in HIV-infected children with chronic lung disease, who are stable on antiretroviral therapy (ART), and identify the prevalence of cardiac dysfunction. The study was conducted at Queen Elizabeth Central Hospital, QECH, a large teaching hospital in Blantyre, Malawi. It was a nested study in a prospective randomised controlled trial that corecruited consenting trial participants with HCLD who had been on ART for more than six months with virological suppression. Chronic lung disease was determined by spirometry of (FEV1 z-score < -1.0) with no reversibility (< 12%). Participant demographics were collected, and cardiac echocardiograms were done at baseline using a Sonosite M-turbo machine (8). Clinical data and demographic data were collected and analysed using STATA 14. Fourty-nine (49) of the 180 participants were recruited. The median age was 14.5 years; the interquartile range [IQR] was 8.4 – 19.8 years; 51.1% female. The mean CD4 cell counts were 640 ± 439 (87 – 2969). The mean Medical Research Council (MRC) dyspnea score was 2.3 ± v 1. Rheumatic heart disease was confirmed in 3 (6%) who were already on treatment at recruitment. 0 (0%) having pulmonary hypertension. In conclusion, our findings demonstrate low cardiac dysfunction and pulmonary hypertension levels in this cohort of HCLD in children. However, there is significant co-morbidity with acquired heart disease in this group set of children. Longer-term follow-up of these children is essential to identify if further cardiac dysfunction does not emerge in children on ART for a longer duration.
- ItemOpen AccessDeterminants of anastomotic leakage among adult bowel surgery patients at Queen Elizabeth Central Hospital, Malawi(2017-10-01) Banda, Rodrick ValeAnastomotic leakages are major complications of bowel surgery with significant implications on patients’ health, prognosis and on health care costs as well. The prevalence of anastomotic leaks (AL) is between 0.5% and 21% after colon and rectal resections [1–5]. The incidence is between 1% and 12% overall and up to 10% to 14% in low colorectal resections [5-8]. In Malawi as in other Sub-Saharan countries, there is limited data on AL. This study seeks to determine the factors predisposing to AL among adult bowel surgery patients at Queen Elizabeth Central Hospital (QECH) • To determine the risk factors for AL among adult bowel surgery patients at QECH Specific objectives • To determine the incidence of bowel AL among adult patients at QECH • To determine the difference in outcomes of bowel surgery performed by surgical trainees and consultant surgeons • To determine the 30-day mortality post bowel AL The study was a retrospective cohort study of the risk factors involved in the occurrence of AL within 30 days post-surgery. Patient’s files were retrieved from the QECH health information management systems for the period January 2008 to December 2016. Over the study period, 185 patients with intestinal anastomosis were identified; the overall leak rate was 16.8% (31/185) and 30-day mortality rate post AL was 35.5% (11/31). In bivariate analysis, 5 factors were associated with AL. Out of these 5 factors, 3 were found to be independent determinants of AL using a logistic regression model: intraperitoneal local sepsis (Relative risk [RR] 7.2, 95%confidence interval [CI] 2.81- 17.5), Haemoglobin level ([<10g/dl] RR 4 ,95% CI 2.167 – 7.5) and Surgeons experience( Trainee/ expert) ( RR 1.4 , 95% CI 1.143-1.957) The knowledge of factors associated with anastomotic leakage after intestinal anastomosis can be modified to reduce AL and improve AL outcomes in our setting
- ItemOpen AccessEmergency care provision and treatment outcomes among under-five children at Mangochi District Hospital(Kamuzu University of Health Sciences, 2021-02-01) Chinyama, Nitta BeniWHO/UNICEF developed ETAT guidelines to help improve child survival. Mangochi hospital adopted ETAT in 2009. The hospital’s status of pediatric emergency care was unknown. The aim of the study was to determine characteristics of users, care provided, and outcomes of the admitted children. This was an uncontrolled before and after study design, conducted to assess pediatric emergencies before and after an intervention in pediatrics’ department for the under-five children, Mangochi, Malawi. The pre-and post-intervention file reviews done retrospectively. The pre was a baseline and followed by a second review following an intervention described below. A checklist developed in line with WHO ETAT guidelines. The tool assesses general socio-demographic, vital signs, triage, laboratory investigations, and availability of basic functional equipment, diagnosis, drug treatment, and patient’s outcome. Descriptive statics were used to analyze continuous and categorical variables. P below .05 was considered significant. The ethical clearance was granted by College of Medicine Research Ethics Committee (COMREC #: P.04/17/2140) after authorization by the local district assembly. Patient gave an informed consent to participate to the study and data were collected anonymously and kept confidential. There was significant increase in all vital signs’ recording post- intervention, except for respiratory rate (p= 0.484). Majority of participants were not triaged (64% vs. 75% respectively). The diagnosis percentages of severe malaria with anemia (12% vs. 0%, p<0.0001), and of severe malaria with severe pneumonia (6.4% vs. 0%, p< 0.0001) decreased significantly. Severe pneumonia (19.7% vs. 29.3%, p< 0.0001), severe head injuries (0.3% vs. 1%; p= 0.0050), sepsis (1.7% vs. 9.0%, p< 0.0001), and unknown conditions (0.3% vs. 1%; p= 0.0050) increased significantly. Initial prescribed drugs were promptly administered (98% vs. 100%). There was a significant decrease of deaths (14.3% to 2%; p< 0.0001), and absconders (5.3% to 0.3%; p=0.0002) post-intervention. Even if results are mixed, most parameters improved following our intervention. Interventions to improve the knowledge of health workers in ETAT coupled with the provision of medical equipment and supplies, improved outcomes are warranted. Challenges in triage need to be investigated further and addressed accordingly.
- ItemOpen AccessAn evaluation of the prevalence, characteristics, outcomes and predictors of shock in children admitted to paediatric wards at Queen Elizabeth Central Hospital in Blantyre, Malawi(Kamuzu University of Health Sciences, 2021-06-01) Kumwenda, MercyShock is an important pathophysiological mechanism of death in children in low-resource settings. Despite this, limited data is available on the prevalence, causes and outcome of shock in children in these settings. We performed a prospective study to assess the prevalence, aetiology and risk factors of death in children with shock. This data will be essential to improve guidelines and interventions to reduce shock related mortality in children. Methods: A prospective descriptive study was performed from 1st February 2019 to 31st January 2020 at Queen Elizabeth Central Hospital (QECH) paediatric department. ALL paediatric admissions screened for shock as defined by FEAST were recruited. The criteria used were impaired consciousness and/or respiratory distress in combination with at least one sign of impaired perfusion: a capillary refill time (CRT) >3 seconds, cold peripheries, weak radial pulse volume and/or severe tachycardia. The WHO definition of shock was used as a comparative definition. Demographic, clinical, laboratory and outcome data were collected from the patient records. Predictors for death were assessed using univariate and multivariate models. Results: Out of 12840 admissions, 679 had shock resulting in a prevalence of 5.3%. Of these 505 were included in the study of 15/439 (3.4%) fulfilled the more stringent WHO criteria for shock. The median age was 17 months and ranged from 2 months to 16 years. Respiratory distress was reported in 397/488 (81.4%), fever in 383/495 (77.4%), vomiting or diarrhoea was reported in 183/484 (37.8%) and 127/478 (26.6%) respectively and severe malnutrition was documented in 39/471 (8.3%). Severe anaemia (Hb ≤5g/dL) was present in 19/334 (5.7%), and 67/395 (17.7%) tested positive for malaria. HIV prevalence was vi 27/358 (7.5%) and blood cultures were positive in 8/176 (4.5%). The main clinical diagnoses on discharge were viral/reactive lower respiratory tract diseases 211/470 (44.9%), pneumonia 89/470 (18.8%), gastroenteritis 64/470 (13.6%) and presumed sepsis 57/470 (12.0%). Overall mortality in shocked children was 79/679 (11.6%). We constructed two multivariate models aimed at a) predicting outcome, and b) assessing disease associated outcomes. Clinical factors predictive of death were low coma score (AOR = 4.9, 95% CI = 2.2 - 11.1), delayed CRT (AOR = 3.5, 95% CI = 1.4 – 8.5) and dehydration (AOR 5.9, 95% CI 3.2 – 11.1). The main clinical diagnoses of children that died were presumed sepsis 34/76 (44.7%), gastroenteritis 21/76 (23.7%), severe malaria 13/76 (17.1%), severe malnutrition 9/76 (11.8%) and meningitis 8/76 (10.5%). In the explanatory model for causative factors, having a diagnosis of presumed sepsis (AOR = 9.9, 95% CI = 4.1 – 23.8) or gastroenteritis (AOR = 3.7, 95% CI = 1.8 – 7.4) was associated with increased mortality, while having viral/reactive airways disease was not associated with death (AOR = 0.02, 95% CI = 0.005 – 0.079). Conclusion: Shock is a common diagnosis in children seen at QECH in Malawi using the modified FEAST criteria, affecting 1 in 18 admissions. The actual prevalence of children with shock may be lower as the FEAST definition we used may have overestimated shock prevalence. This was evidenced by the fact that approximately 40% of those that qualified had a purely respiratory condition and only 3.4% of those who qualified fit the very strict WHO definition. This discrepancy underlines the lack of a valid bedside definition for shock in children in Malawi. In our population, mortality was high at 11%. The children who present with a low BCS, delayed CRT and dehydration were more likely to die. The diagnoses of sepsis, gastroenteritis and malaria were contributors to death. This might underscore the importance of their prompt treatment.
- ItemOpen AccessImpact of depression and other common mental disorders on antiretroviral treatment outcomes among Malawian women in the PEPFAR-promote study(Kamuzu University of Health Sciences, 2022-03-01) Dula, Dingase ElizabethCommon mental disorders (CMDs) are highly prevalent among people living with HIV(PLWHIV). If left untreated, they negatively affect HIV treatment outcomes. Low cost, low intensity interventions for CMDs such as Friendship Bench problem solving therapy (FB-PST) are being adopted in various clinical care settings. There is need to test effectiveness of these interventions in randomized controlled trials. The objectives of this study was to determine the prevalence of Common Mental Disorders (CMDs) among Women living with HIV (WLHIV) on lifelong antiretroviral therapy (ART) and efficacy of Friendship Bench Problem Solving Therapy (FB-PST) on CMD symptoms and viral load (a composite marker of ART adherence). A randomized FB-PST intervention among WLHIV at the Blantyre, Malawi site co-enrolled in the multi-country PEPFAR PROMOTE cohort study was conducted, with 18 months follow-up for HIV-ART outcomes. Standardized Self Reporting Questionnaire (SRQ)-20 was used to screen for CMDs (March 2018- Dec 2018). Eligible women with a CMD without suicidality were randomized to receive FB-PST (trained study peer-counselors) or referred for standard-of-care (SOC) treatment. Prevalence of SRQ-20 based CMD was high, 65/326 (19.9%); of these, 52 eligible women were randomized to FB-PST or SOC (1:1 ratio). Pre-intervention, 48 (90.6%) participants diagnosed with CMD had VL<1000 copies/ml and 160 (89.4%) without CMD had VL<1000 copies/ml (p=0.804). 14(21.5%) CMD sufferers reported suicidality. At 6 months postintervention, 26(100%) FB-PST treated women had VL <1000 copies/ml versus 18(69.2%) women in SOC arm (p= 0.005). At 12 months post-intervention, 26(100%) in the FB-PST arm maintained VL <1000 copies/ml versus vii 18(69.2%) in the SOC-treated arm. 18 months post-intervention, 18 (69.2%) women in the FB-PST arm had VL<1000copies/ml compared to 8 (30.7%) in the SOC arm (p=0.062). 14 (53.8%) treated with FB-PST had CMD resolution (SRQ score <8) 6 months post- intervention versus 16 (61.5%) in the SOC arm (p=0.804). In conclusion, there was high prevalence of CMDs among WLHIV. Task shifting models of CMD treatment such as Friendship Bench PST are potentially as effective as standard of care in improving CMD symptoms and HIV treatment outcomes if they are delivered in their entirety as intended.