Being in limbo: the experience of critical illness in intensive care and beyond

Critical illness is a sudden traumatising lived experience that affects the sufferer and their family throwing them into a crisis situation. It is disruptive and alienating. Critically ill patients emerging from unconsciousness often suffer from confusion that could be momentary or lasting. There is an increasing number of critical illness survivors in intensive care units (ICU)1 with numerous life changing ongoing physiological and psychological sequelae from critical illness and ICU hospitalization, with inadequate ongoing treatment for ICU survivors. Medicalised accounts of critical illness fail to recognise the significant impact on the person, their embodied sense of self and their ability to move on with their life after they leave hospital. The main purpose of this study was to explore the experience of critically ill patients in ICU and beyond. This phenomenological study describes what it was like for twelve people to experience critical illness in ICU and in the months after discharge. The finding was that critical illness is an acute life threatening event with long lasting effects which translate into temporal and biographical disruption, imprisonment by the ICU and its therapies and being trapped in an alien body that is plagued by uncertainty and long lasting conditions arising from the critical illness and the ICU therapies. Critical illness survivors are left in a state of limbo characterised by a struggle to reclaim their precritical illness ICU identity and uncertainty about their future. Hence an overarching theme of being in limbo under which three major themes of 1) disruption, 2) imprisonment and 3) being trapped were generated from the study

Exploring community participation in a diarrhoea prevention program in Kanyama, Lusaka, Zambia

Magister Public Health - MPHThe program that was studied is part of the Child Health Program devised and supported by CARE International and implemented in Kanyama, a high density and low cost community found on the outskirts of Lusaka, Zambia. Diarrhoea was identified as one of the three most common diseases affecting the children under the age of five years. Through community participation, the program was implemented by the Kanyama residents to reduce the cases of diarrhoea, malaria and pneumonia among children aged five years and under. The main aim of this study was to explore the perceptions of the impact of community participation by the community leaders and community members in the diarrhoea prevention program and to establish constraints affecting participation.South Afric

A third trial oversight committee: Functions, benefits and issues

BACKGROUND/AIMS: Clinical trial oversight is central to the safety of participants and production of robust data. The United Kingdom Medical Research Council originally set out an oversight structure comprising three committees in 1998. The first committee, led by the trial team, is hands-on with trial conduct/operations (‘Trial Management Group’) and essential. The second committee (Data Monitoring Committee), usually completely independent of the trial, reviews accumulating trial evidence and is used by most later phase trials. The Independent Data Monitoring Committee makes recommendations to the third oversight committee. The third committee, (‘Trial Steering Committee’), facilitates in-depth interactions of independent and non-independent trial members and gives broader oversight (blinded to comparative analysis). We investigated the roles and functioning of the third oversight committee with multiple research methods. We reflect upon these findings to standardise the committee’s remit and operation and to potentially increase its usage. METHODS: We utilised findings from our recent published suite of research on the third oversight committee to inform guideline revision. In brief, we conducted a survey of 38 United Kingdom–registered Clinical Trials Units, reviewed a cohort of 264 published trials, observed 8 third oversight committee meetings and interviewed 52 trialists. We convened an expert panel to discuss third oversight committees. Subsequently, we interviewed nine patient/lay third committee members and eight committee Chairs. RESULTS: In the survey, most Clinical Trials Units required a third committee for all their trials (27/38, 71%) with independent members (ranging from 1 to 6). In the survey and interviews, the independence of the third committee was valued to make unbiased consideration of Independent Data Monitoring Committee recommendations and to advise on trial progress, protocol changes and recruitment issues in conjunction with the trial leadership. The third committee also advised funders and sponsors about trial continuation and represented patients and the public by including lay members. Of the cohort of 264 published trials, 144 reported a ‘steering’ committee (55%), but the independence of these members was not described so these may have been internal Trial Management Groups. Around two thirds of papers (60%) reported having an Independent Data Monitoring Committee and 26.9% neither a steering nor an Independent Data Monitoring Committee. However, before revising the third committee charter (Terms of Reference), greater standardisation is needed around defining member independence, composition, primacy of decision-making, interactions with other committees and the lifespan. CONCLUSION: A third oversight committee has benefits for trial oversight and conduct, and a revised charter will facilitate greater standardisation and wider adoption

Womens experiences of HIV testing and counselling in the labour ward: A case of Bwaila hospital

Introduction: HIV counseling and testing during labour can be emotional, but is important because it allows mothers and babies to receive PMTCT prophylaxis if previous identification of HIV infection has not occurred. The study explores how HIV testing and counseling during early labour affects women.Methodology: This was a qualitative exploratory study to understand women’s experiences during early labor. From September to October 2009, we conducted 10 indepth interviews with women who tested for HIV during early labour. We recruited women who tested > 3 months previously and those who had never tested for HIV from the postpartum ward of Bwaila Hospital. Data were analyzed manually using the life story approach in order to examine and analyse subjective experiences of women and their constructions of the social world. Transcripts were read multiple times to understand meanings which participants attached to their experiences. We coded data according to emerging themes and subthemes.Results: Ten women 20-35 years were interviewed. Eight women had unknown HIV status while two had known HIV results but re-tested to update their status. Four women were found HIV-positive while 6 were  HIVnegative. The primary theme was that women appreciated and accepted HIV testing and counseling. Testing was accepted as a necessary step to protect the infant from HIV infection. Counseling was viewed as helpful for acceptance of HIV status. One key subtheme was that HIV positive women experienced disappointment about their HIV diagnosis, though this was outweighed by the knowledge that one could protect her infant. All women viewed the short time to complete the counseling and testing procedures as favourable.Conclusion: Labour testing is acceptable and should be promoted to enhance PMTCT services by identifying HIV positive women with unknown status. Counseling helps women to accept being found with HIV and seek appropriate services

Developing the UNICEF Malawi school handwashing program

Diarrhea is one of the major causes of morbidity and mortality among children and immune-compromised individuals in Malawi. Handwashing with soap (HWWS) is one of the most cost-effective health interventions to prevent diarrhea. United Nations Children’s Fund (UNICEF) Malawi has adopted a social marketing approach to achieve large-scale behavioral change for HWWS. The study, commissioned by UNICEF Malawi, was developed by PSI Malawi and Griffith University and conducted by PSI Malawi. Formative research insights using two research studies are presented including observations at 30 primary schools in terms of HWWS behavior. Second, key informant interviews with school administrators and staff members were conducted to understand HWWS motivation, opportunity, and ability factors. This study found less than half of the assessed schools had handwashing facilities. Structural barriers that prevent school children from practicing HWWS were identified including a lack of financial resources to construct permanent handwashing facilities in schools. Many schools also experience a lack of support from the community as citizens are not aware of the benefits of HWWS. Changes to school and community infrastructure are required to facilitate the adoption of the behavior. Supporting activities to encourage school children to practice HWWS and reinforcement strategies to sustain the behavior over time should also be implemented. School children can then become change agents for HWWS by reinforcing the behavior at home thereby contributing to the achievement of the national objectives to reduce diarrhea and leading to improved health and well-being for communities in Malawi

Bioactivity of common pesticidal plants on fall armyworm larvae (spodoptera frugiperda)

The fall armyworm (FAW), Spodoptera frugiperda (Lepidoptera: Noctuidae) is a recent invasive pest species that has successfully established across sub‐Saharan Africa where it continues to disrupt agriculture, particularly smallholder cereal production. Management of FAW in its native range in the Americas has led to the development of resistance to many commercial pesticides before its arrival in Africa. Pesticide use may therefore be ineffective for FAW control in Africa, so new and more sustainable approaches to pest management are required that can help reduce the impact of this exotic pest. Pesticidal plants provide an effective and established approach to pest management in African smallholder farming and recent research has shown that their use can be cost‐beneficial and sustainable. In order to optimize the use of botanical extracts for FAW control, we initially screened ten commonly used plant species. In laboratory trials, contact toxicity and feeding bioassays showed differential effects. Some plant species had little to no effect when compared to untreated controls; thus, only the five most promising plant species were selected for more detailed study. In contact toxicity tests, the highest larval mortality was obtained from Nicotiana tabacum (66%) and Lippia javanica (66%). Similarly, in a feeding bioassay L. javanica (62%) and N. tabacum (60%) exhibited high larval mortality at the highest concentration evaluated (10% w/v). Feeding deterrence was evaluated using glass‐fibre discs treated with plant extracts, which showed that Cymbopogon citratus (36%) and Azadirachta indica (20%) were the most potent feeding deterrents among the pesticidal plants evaluated. In a screenhouse experiment where living maize plants infested with fall armyworm larvae were treated with plant extracts, N. tabacum and L. javanica were the most potent species at reducing foliar damage compared to the untreated control whilst the synthetic pesticide chlorpyrifos was the most effective in reducing fall armyworm foliar damage. Further field trial evaluation is recommended, particularly involving smallholder maize fields to assess effectiveness across a range of contexts

Cardiac Cysticercosis and Neuro Cysticercosis in Sudden and Unexpected Community Deaths in Lusaka, Zambia – A Descriptive Medico-Legal Post-Mortem Examination Study

Background: Cysticercosis is a World Health Organization designated neglected human zoonosis worldwide. Data on cardiac cysticercosis and its contribution to sudden and unexpected community deaths are scarce and require study. Methods: A study was performed of cysticercosis-related deaths and other incidental cases of cysticercosis seen at forensic post-mortem examination over a period of 12 months, in individuals who died suddenly and unexpectedly in the community in Lusaka, Zambia. Whole-body post-mortem examinations were performed according to standard operating procedures for post-mortem examinations. Representative samples were obtained from all body organs and subjected to histopathological examination. Information was obtained on circumstances surrounding the death. Data were collated on patient demographics, history, co-morbidities, pathological gross and microscopic findings, and forensic autopsy cause(s) of death. The available literature on cardiac cysticercosis was also reviewed. Results: Nine cases of cysticercosis were identified. Eight of the nine cases had cardiac cysticercosis. There was no prior history of cysticercosis before death. All were male, aged between 28 and 56 years, and from high population density and low socioeconomic communities. There was no community case clustering identified. Conclusions: Cardiac cysticercosis and neurocysticercosis are important incidental findings in sudden and unexpected deaths in the community and can easily be missed antemortem. More investment in forensic autopsy services is required to define the undiagnosed burden of deaths due to treatable communicable diseases

Evaluating the benefits of incorporating traditional birth attendants in HIV Prevention of Mother to Child Transmission service delivery in Lilongwe, Malawi

The objective of our intervention was to examine the benefits of incorporating traditional birth attendants (TBA) in HIV Prevention of Mother to Child Transmission (PMTCT) service delivery. We developed a training curriculum for TBAs related to PMTCT and current TBA roles in Malawi. Fourteen TBAs and seven TBA assistants serving 4 urban health centre catchment areas were assessed, trained and supervised. Focus group discussions with the TBAs were conducted after implementation of the program. From March 2008 to August 2009, a total of 4017 pregnant women visited TBAs, out of which 2133 (53.1%) were directly referred to health facilities and 1,884 (46.9%) women delivered at TBAs and subsequently referred. 168 HIV positive women were identified by TBAs. Of these, 86/168 (51.2%) women received nevirapine and 46/168 (27.4%) HIV exposed infants received nevirapine. The challenges in providing PMTCT services included lack of transportation for referrals and absence of a reporting system to confirm the woman’s arrival at the health center. Non-disclosure of HIV status by patients to the TBAs resulted in inability to assist nevirapine uptake. TBAs, when trained and well-supervised, can supplement efforts to provide PMTCT services in communities. (Afr J Reprod Health 2014; 18[1]: 27-34).Keywords: Traditional Birth Attendants, PMTCT, Malaw

Anatomical variations and morphometric properties of the circulus arteriosus cerebri in a cadaveric Malawian population

Background: Knowledge of the anatomy of the circulus arteriosus cerebri (CAC) is important in understanding its role as an arterial anastomotic structure involved in collateral perfusion and equalization of pressure, and may explain observed variations in neurovascular disease prevalences across populations. This study was aimed at understanding the anatomical configuration and morphometric properties of the CAC in Malawian population. Materials and methods: Brains were collected from 24 recently-deceased black Malawian human cadavers during medico-legal autopsies. Photographs of the CACs were taken using a camera placed at a 30 cm height from the base of the brain. Whole-circle properties and segmental vessel parameters were analyzed using the OSIRIS computer program, paying attention to completeness, typicality, symmetry, and segmental vessel diameters and lengths. Results: 69.57 % of the CACs exhibited the complete-circle configuration. Of these, 37.5 % were typical, representing an overall typicality prevalence of 26.09 %. Vessel asymmetry was observed in 30.43 % of cases. There were 7 cases of vessel aplasia and 12 cases of vessel hypoplasia. The posterior communicating artery (PcoA) was the most variable (with 12 variations), widest (7.67 mm) and longest (27.7 mm) vessel while the anterior communicating artery (AcoA) was the shortest (0.78mm). Both the AcoA and the PcoA were the narrowest vessels (0.67 mm) in this study. CAC variations in Malawian populations appeared to be similar to those observed in diverse populations. Conclusions: Anatomical variations of the circulus arteriosus cerebri exist in Malawian population and should be taken into consideration in clinical practice

Investigating the suitability and cost-benefit of copper tailings as partial replacement of sand in concrete in Zambia: An exploratory study

Purpose: This study investigated the suitability and cost-benefit of using copper tailings as partial replacement of sand in concrete production. The study was motivated by the accumulation and non- utilisation of Copper Tailings in dams among them Tailing Dam 25 also known as TD 25 in Kitwe city of the Copperbelt province in Zambia that take up approximately 111 hectares of unutilised land. Design/methodology/approach: Laboratory experimental approach of concrete production based on water/cement ratios of 0.3 and 0.5 was used because this was an exploratory study designed to establish the primary performance of .concrete. 30 concrete cubes were cast based on the two water-cement ratios. 0% to 30% partial sand replacement with copper tailings was used in both mixes with the 0% copper tailings replacement being the control mix and reference point. Other concrete tests included workability, density, compressive strength and element composition analysis. Findings: Results revealed that copper tailings from TD 25 were suitable for partial replacement of sand in concrete. 30% of sand replacement with copper tailings was established as the maximum replacement amount in order to produce optimum compressive strength values from both mixes. The drier mix of 0.3 water-cement ratio produced higher compressive strength results of 23 MPa at 28 days of concrete curing with 2.34% as optimum concrete cost reduction. Originality/Value: The study provides guidance on optimum concrete grade produced and cost reduction details of copper tailing-based concrete to support for local authorities in suitable land wand waste management using real data