Browsing by Author "Rylance, Jamie"
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- ItemRestrictedBefore BREATHE: A baseline audit of hypoxemia in Malawi(2022-09-16) Rylance, JamieExecutive summary 4.1 Type of research study The study is a prospective audit. 4.2 Problem to be addressed Our team’s study at Queen Elizabeth Central Hospital (QECH) in 2012 showed tha one third of medical patients had a respiratory diagnosis, and hypoxia was not identified in 21% of these. Furthermore, only one third of those requiring oxygen by WHO guidelines were receiving it.1z Due to the COVID-19 pandemic, interest in improving outcomes for all hypoxemic patients in LICs has increased, with proposals including increases in oxygen supplies, improvements in systems for monitoring hypoxemia and titrating oxygen therapy, and testing of various oxygen delivery devices. This audit will provide updated information on the practices, and outcomes for oxygen monitoring and titration at QECH. The information collected for this audit will provide the necessary platform from which future quality improvement and research studies can be developed. Parallel data collection will occur in Rwanda and Kenya as part of the assessment of potential sites for a prospective trial of high flow oxygen. 4.3 Broad objective To understand oxygen supply and demand at Queen Elizabeth Central Hospital, Malawi. 4.4 Specific objectives 1. To describe the physical resources and current practices for oxygen therapy for hypoxemic adults at QECH. 2. To measure the baseline performance of key indicators for optimal oxygen monitoring, documentation, and titration. 3. To assess in-hospital outcomes of mortality and length of stay for all hypoxemic adults. 4.5 Methodology Prospective audit of data recorded in the patient medical notes and charts. The audit will continue for three months to give information on an estimated 300 patients (based on local patterns), which will allow confidence in the representativeness, and ability to detect low levels of non-compliance with hospital guidelines. To estimate mortality, this number gives a 5.7% precision around a prior estimate of 50%.16-Sep-2022 Before BREATHE: a baseline audit of hypoxaemia protocol (version 1.0)Before BREATHE: a baseline audit of hypoxaemia protocol (version 2.0) - 06/03/202201/09/2022 Page 6 of 16 4.6 Findings and dissemination Data collected by the audit team will be freely available to, and owned by, the hospital. We hope that this will allow an assessment of current practice, and inform repeated quality- improvement cycles. The audit data will be used to power a future randomised controlled trial of alternative (high flow) oxygen therapy. We will work with our team to present the findings to hospital grand rounds, and to publish, for example, in the Malawi Medical Journal. We will also feedback directly to COMREC.
- ItemRestrictedChildren’s air pollution profiles in Africa (CAPPA) v1.0, 20/02/21(Kamuzu University of Health Sciences, 2021-06-03) Rylance, JamieExecutive Summary - The type of research study This is a multi-centre observational cohort study about air pollution in African children. The centres included are in Malawi, Tanzania, Uganda, Zimbabwe, Ghana, South Africa, and Nigeria. - The problem to be studied There is extensive literature on the wide-ranging health impacts of exposure to air pollution on populations. Children are vulnerable due to their developing bodies (Gehring et al., 2013, Gauderman, 2007); evidence shows that children’s lungs exposed to higher levels of air pollution have less volume than those in cleaner areas (Mudway et al., 2019). While personal exposure studies are becoming established in Europe, no such large-scale studies have yet been carried out on the African continent. This study aims to close that gap, providing valuable evidence to help improve the health of Africa’s young population. - The objectives [i] Broad The study aims to describe the burden of personal air pollution exposure (particulate matter <10 and <2.5 microns (PM10/2.5), and nitrogen dioxide (NO2)) in urban children with asthma symptoms in sub-Saharan Africa, its geographic, and temporal variability, the role of indoor and outdoor microenvironments and activity profiles, and effect of socioeconomic variables. To assess how personal air pollution exposure affect children with asthma symptoms in urban Sub-Saharan Africa, and the influence of socioeconomic factors on the effects. [ii] Specific 1. To collect personal air pollution exposure data, activity profiles, and lung function measurements from 60 children with asthma symptoms aged between 12 and 14 years, in Blantyre, Malawi. 2. To analyse personal air pollution data for exposure patterns and peak exposures. 2.3., and tTo compare air pollution as well as activity profiles of children in relation to their socioeconomic and geographical backgrounds both within and between countries, and compare with measured data from school-age children in London. 3.4.To explore potentially detrimental effects of air pollution, and feasibility of mitigation strategies in children with asthma symptoms identified by ACACIA. - Methodology From March 2021, we will recruit 60 children who participated in the ACACIA study. The participant will be provided a backpack fitted with air monitoring equipment to carry and keep close to them. Each child’s exposure to NO2 and PM2.5, as well as their GPS-location, temperature and humidity, will be collected at a 1-second intervals for 96 hours, and stored on a microchip within the backpacks’ logging unit. The data analysis procedure will follow that developed for a previous similar study in London – ‘Breathe London Wearables’1. Once monitoring at a site is complete, encrypted data will be uploaded from the backpack sensor units to a secure server where it will be decrypted. The digital CAPPA questionnaire will be filled in by each participant and will provide additional information regarding each participant’s personal exposure. Participants will also measure and record their lung function twice a day using a peak flow meter. - Expected findings and their dissemination This study will increase knowledge on air pollution exposure of young people in Blantyre, Malawi. The study will provide data on exposure to harmful pollutants and the risk to children’s health in this increasingly urbanised region. Links between data on respiratory health of young participants who experience asthma symptoms with air pollution exposure data will be explored and will lead to new insights. A copy of the final report, published papers, and conference abstracts will be submitted to; the College of Medicine Research and Ethics Committee, the College of Medicine Library, the Health Sciences Research Committee, and the University Research and Publication Committee.
- ItemRestrictedMultimorbidity associated with emergency hospital admissions. A screen and link strategy to improve outcomes for high risk patients in Sub-Saharan Afica(2022-05-09) Rylance, JamieType and place of study: This is a prospective longitudinal cohort study of adult acute medical hospital admissions with nested situation analysis and health economic measures, to screen and link for multimorbidity in Africa. It will be based at: 1. Queen Elizabeth Central Hospital, Blantyre, Malawi 2. Chiradzulu District Hospital, Southern Region, Malawi 3. Hai District Hospital, Moshi, Tanzania 4. Muhimbili National Hospital, Dar-es-Salaam, Tanzania Problem: Sub-Saharan Africa suffers from an interplay of high rates of infectious disease and rising prevalence of non-communicable diseases, resulting in multimorbidity. Importantly, HIV (and anti-retroviral treatment) can accelerate non-communicable disease. Patients frequently delay seeking treatment until they are severely ill and require emergency management. Hospital care then predominantly focusses on the primary presenting problem, overlooking multimorbidity. This oversight precipitates frequent hospital admissions, increases health system and out-of-pocket expenses, and leads to disability and death. Main objective: Determine prevalence of multimorbid disease in acute adult medical admissions, clustering of diseases as part of multimorbidity, and their effect on patient outcomes including quality of life and incurred costs.. Secondary objectives: 1. Determine Hhospital readmission free survival 90 days after admission; markers of disease control 90 days after admission; rate of end-organ damage (e.g. CVA, MI, ESRF) 90 days after admission; 2. Obtain a qualitative description of healthcare pathways through ; situation analysis of healthcare pathways forof acute medical admissions, and; qualitative exploration of health literacy and experience of care for patients with multimorbidity. 3. Estimate direct and indirect healthcare costs (from provider and patient perspectives) of care for patients with multimorbidity. Methodology: We will recruit adults (≥18 years) admitted to hospital as a medical emergency (n=1548 participants) into a longitudinal cohort study with nested situation analysis & health economic evaluation. Follow-up duration will be 90 days from hospital admission. The study is planned for 18 months; estimated end April 2023. We will use deferred emergency recruitment with retrospective consenting procedures, consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites to ensure balance and mitigate against recruitment bias. In parallel with quantitative data collection from tablet based structured09-May-2022 Multilink cohort study REC submission v1v2.0 – COMREC28/10/202128/03/2022 Page 8 of 45 questionnaire using standardised tools, we will use point of care blood and urine tests to refine estimates of disease pathology, making these available to the medical teams (see Table 1) . We will use qualitative interviews with healthcare workers in a portion of treating providers after patient discharge. Qualitative interviews will also take place with a proportion of patients after follow up visit at 90 days. Expected findings: The main outcome measure is the individual and multimorbid prevalence of hypertension, diabetes mellitus, HIV-infection and chronic kidney disease in adults admitted with acute medical condition. Secondary outcome measures includeare: 90-day survival and readmission after acute admission; Interim hospital readmission within 90 days of admission; diagnosis and control of hypertension (WHO criteria); diagnosis and control of, diabetes mellitus, (WHO criteria); diagnosis and control, including ARV complianceHIV and viral load) of HIV infection (WHO definitions);, and diagnosis and control of chronic kidney disease (KDOQI). The data will allow a clear estimate of the prevalence and constitution of multimorbidity according to a standard definition of “two or more concurrent chronic medical pathologies”. The size of the cohort will allow us to estimate prevalence look for intersections of diseasemultimorbidity, including those which occur more commonly in association i.e. “clustering”. This will be for first formal description of multimorbidity amongst inpatients in sub- Saharan Africa. It will allow the researcher network, which is closely tied to policymaking and community representatives, to understand what an intervention to identify multimorbidity might look like. After presentation of these data, and consultation, we will co-design such an intervention and design a protocol to test it using a cluster-randomised controlled trial. Dissemination: Will be done through policy and stakeholder networks, international conferences and presentation, and direct feedback to COMREC
- ItemRestrictedOxygen requirements and approaches to respiratory support in patients with COVID-19 in low- and middle-income countries: a WHO O2 CoV2 study(2022-02-09) Rylance, JamieType of research study The study is a prospective cohort (inception) study. 4.2 Problem to be addressed It is estimated that approximately 20% of those affected by COVID-19 require oxygen supportive therapy. Oxygen is an essential medicine and has been listed as such on the WHO Essential Medicines List and Essential Medicines List for children for almost two decades. Still, availability of supplemental medical oxygen in low- and middle-income countries (LMICs) remains a challenge. The COVID-19 pandemic has highlighted, more than ever, the acute need for scale-up of oxygen therapy. WHO has provided an inventory tool to quantify facility-level provision of infrastructure to deliver oxygen therapy. Some data are available from existing studies, however, detailed data on the use of oxygen therapy in LMICs at the patient level remain lacking. The WHO COVID-19 Clinical Characterization and Management Research Group has been developing two research protocols to support the understanding of respiratory support practices and oxygen requirements for the clinical management of COVID-19. The first is an observational study to describe oxygen requirements and respiratory support practices at facilities caring for patients with COVID-19 in LMICs. The second is an interventional platform trial which seeks to compare modalities of respiratory support (continuous positive airway pressure [CPAP] vs high-flow nasal cannula [HFNC], awake prone position). Selection of the most relevant interventions requires an understanding of current practice and expertise in sites that might recruit patients to the trial. Existing studies collect data on oxygen mode of delivery, but do not characterize the type, quantity and duration of each modality’s use at the patient level, to give a better understanding of oxygen therapy modalities in current use in LMICs