Evaluation of 'TRY': an algorithm for neonatal continuous positive airways pressure in low-income settings

BACKGROUND: Non-invasive respiratory support using bubble continuous positive airway pressure (bCPAP) is useful in treating babies with respiratory distress syndrome. Despite its proven clinical and cost-effectiveness, implementation is hampered by the inappropriate administration of bCPAP in low-resource settings. A clinical algorithm-'TRY' (based on Tone: good; Respiratory distress; Yes, heart rate above 100 beats/min)-has been developed to correctly identify which newborns would benefit most from bCPAP in a teaching hospital in Malawi. OBJECTIVE: To evaluate the reliability, sensitivity and specificity of TRY when employed by nurses in a Malawian district hospital. METHODS: Nursing staff in a Malawian district hospital baby unit were asked, over a 2-month period, to complete TRY assessments for every newly admitted baby with the following inclusion criteria: clinical evidence of respiratory distress and/or birth weight less than 1.3 kg. A visiting paediatrician, blinded to nurses' assessments, concurrently assessed each baby, providing both a TRY assessment and a clinical decision regarding the need for CPAP administration. Inter-rater reliability was calculated comparing nursing and paediatrician TRY assessment outcomes. Sensitivity and specificity were estimated comparing nurse TRY assessments against the paediatrician's clinical decision. RESULTS: Two hundred and eighty-seven infants were admitted during the study period; 145 (51%) of these met the inclusion criteria, and of these 57 (39%) received joint assessments. The inter-rater reliability was high (kappa 0.822). Sensitivity and specificity were 92% and 96%, respectively. CONCLUSIONS: District hospital nurses, using the TRY-CPAP algorithm, reliably identified babies that might benefit from bCPAP and thus improved its effective implementation

A profile of elderly fallers referred for physiotherapy in the emergency department of a Dublin teaching hospital.

Ireland has an ageing population and the elderly are over-represented in Emergency Departments (ED)--a quarter of these presentations resulting from falls. A prospective study design was employed using a convenience sample to profile elderly fallers referred for physiotherapy in ED. Forty-subjects were assessed over 14 weeks. Mean age was 84.88 years (s.d. 7.3) and 31 (77.5%) were female. All demonstrated slow walking speed and 26 (65%) demonstrated poor grip strength. A quarter of subjects reported fear of falling and 30 (75%) were classified as frail. Elderly fallers in ED are a frail group of socially vulnerable patients who demonstrate a risk of further falls. Osteoporosis had been diagnosed in 9 (22.5%) subjects--a low prevalence compared with international research, but 25 (62.5%) subjects had never had a DEXA scan. The prevalence of frailty in the sample of elderly fallers in this study was very high (75%)

Semiclassical transmission across transition states

It is shown that the probability of quantum-mechanical transmission across a phase space bottleneck can be compactly approximated using an operator derived from a complex Poincar\'e return map. This result uniformly incorporates tunnelling effects with classically-allowed transmission and generalises a result previously derived for a classically small region of phase space.Comment: To appear in Nonlinearit

Small denominators, frequency operators, and Lie transforms for nearly integrable quantum spin systems

Based on the previously proposed notions of action operators and of quantum integrability, frequency operators are introduced in a fully quantum-mechanical setting. They are conceptually useful because another formulation can be given to unitary perturbation theory. When worked out for quantum spin systems, this variant is found to be formally equivalent to canonical perturbation theory applied to nearly integrable systems consisting of classical spins. In particular, it becomes possible to locate the quantum-mechanical operator-valued equivalent of the frequency denominators that may cause divergence of the classical perturbation series. The results that are established here link the concept of quantum-mechanical integrability to a technical question, namely, the behavior of specific perturbation series

Talking South African fathers: a critical examination of men’s constructions and experiences of fatherhood and fatherlessness

The absence of biological fathers in South Africa has been constructed as a problem for children of both sexes but more so for boy-children. Arguably the dominant discourse in this respect has demonized non-nuclear, female-headed households. Fathers are constructed as either absent or ‘bad’. Thus it has become important to explore more closely how male care-givers have been experienced by groups of men in South Africa. This article examines discourses of fatherhood and fatherlessness by drawing on qualitative interviews with a group of 29 men who speak about their reported experiences and understandings of being fathered or growing up without biological fathers. Two major and intertwined subjugated discourses about adult men’s experiences of being fathered that counter- balance the prevailing discourses about meaning of fatherhood and fatherlessness became evident, namely, ‘being always there’ and ‘talking fatherhood’. The importance of the experience of fatherhood as ‘being there’, which relates to a quality of time and relationship between child and father rather than physical time together, is illustrated. It is not only biological fathers who can ‘be there’ for their sons but also social fathers, other significant male role models and father figures who step in at different times in participants’ lives when biological fathers are unavailable for whatever reason. Second, many positive experiences of fathers or father figures that resist a traditional role of authority and control and subscribe to more nurturant and non-violent forms of care, represented as ‘talking’ fathers, are underlined. If we are to better understand the impact of colonial and apartheid history and its legacy on family life in contemporary society, there is a need for more historically and contextually informed studies on the meaning of fatherhood and fatherlessness.Web of Scienc

Admissions to a low resource neonatal unit in Malawi using The NeoTree application: A digital perinatal outcome audit

Background: Mobile-health has increasing potential to address health outcomes in under-resourced settings as smart-phone coverage increases. The NeoTree is a mobile-health application co-developed in Malawi to improve the quality of newborn care at the point of admission to neonatal units. While collecting vital demographic and clinical data this interactive platform provides clinical decision-support, and training for the end-users (health care workers (HCW)), according to evidence based national and international guidelines. Objective: Our aims were to examine one month of data collected using the NeoTree in an outcome audit of babies admitted to a district-level neonatal nursery in Malawi and to demonstrate proof of concept of digital audit data in this setting. Methods: Using a phased approach over one month (21 Nov – 19 Dec, 2016), frontline HCWs were trained and supported to use the NeoTree to admit newborns. Discharge data were collected by the research team using a discharge form within the NeoTree ‘NeoDischarge’. Descriptive analysis was conducted on the exported pseudonomysed data and presented to the newborn care department as a digital audit. Results: Of 191 total admissions, 134 (70%) admissions were completed using the NeoTree and 129 (67%) were exported and analysed. Of these 129, 102 (79%) were discharged alive. Overall case fatality rate was 93 per 1000 admitted babies. Prematurity with respiratory distress syndrome, Birth Asphyxia, and Neonatal sepsis contributed to 41.6%, 58.3% and 16.6% of deaths respectively. Deaths may have been under-reported due to phased implementation and some families of babies with imminent deaths self-discharging home. Detailed characterisation of the data enabled departmental discussion of modifiable factors for quality improvement, for example improved thermoregulation of infants. Conclusions: This digital outcome audit demonstrates that data can be captured digitally at the bedside by HCWs in under-resourced newborn facilities and these data can contribute to meaningful review of quality of care/outcomes and potential modifiable factors. Coverage may be improved during future implementation by streamlining the admission process to be solely via digital format. Our results present a new methodology for newborn audit in low-resource settings and are a proof of concept for a novel newborn data system in these settings

'Family comes in all forms, blood or not': disrupting dominant narratives around the patriarchal nuclear family

After nearly 25 years of democracy, lives of young South Africans are still profoundly shaped by the legacies of apartheid. This paper considers how these differences are produced, maintained and disrupted through an exploration of changing narratives developed by a small group of South African pre-service teachers, with a particular focus on the narratives developed around discourses of fatherhood generally and absent fathers in particular. We draw on interviews conducted with three students in which we discussed their digital stories and literature reviews. In this paper, we draw attention to the limitations of digital storytelling and the risks such autobiographical storytelling presents of perpetuating dominant narratives that maintain and reproduce historical inequalities. At the same time, in highlighting ways in which this risk might be confronted, the paper also aims to show the possibilities in which these dominant narratives may be challenged.IBS

Admissions to a Low-Resource Neonatal Unit in Malawi Using a Mobile App and Dashboard: A 1-Year Digital Perinatal Outcome Audit

Introduction: Understanding the extent and cause of high neonatal deaths rates in Sub-Saharan Africa is a challenge, especially in the presence of poor-quality and inaccurate data. The NeoTree digital data capture and quality improvement system has been live at Kamuzu Central Hospital, Neonatal Unit, Malawi, since April 2019. Objective: To describe patterns of admissions and outcomes in babies admitted to a Malawian neonatal unit over a 1-year period via a prototype data dashboard. Methods: Data were collected prospectively at the point of care, using the NeoTree app, which includes digital admission and outcome forms containing embedded clinical decision and management support and education in newborn care according to evidence-based guidelines. Data were exported and visualised using Microsoft Power BI. Descriptive and inferential analysis statistics were executed using R. Results: Data collected via NeoTree were 100% for all mandatory fields and, on average, 96% complete across all fields. Coverage of admissions, discharges, and deaths was 97, 99, and 91%, respectively, when compared with the ward logbook. A total of 2,732 neonates were admitted and 2,413 (88.3%) had an electronic outcome recorded: 1,899 (78.7%) were discharged alive, 12 (0.5%) were referred to another hospital, 10 (0.4%) absconded, and 492 (20%) babies died. The overall case fatality rate (CFR) was 204/1,000 admissions. Babies who were premature, low birth weight, out born, or hypothermic on admission, and had significantly higher CFR. Lead causes of death were prematurity with respiratory distress (n = 252, 51%), neonatal sepsis (n = 116, 23%), and neonatal encephalopathy (n = 80, 16%). The most common perceived modifiable factors in death were inadequate monitoring of vital signs and suboptimal management of sepsis. Two hundred and two (8.1%) neonates were HIV exposed, of whom a third [59 (29.2%)] did not receive prophylactic nevirapine, hence vulnerable to vertical infection. Conclusion: A digital data capture and quality improvement system was successfully deployed in a low resource neonatal unit with high (1 in 5) mortality rates providing and visualising reliable, timely, and complete data describing patterns, risk factors, and modifiable causes of newborn mortality. Key targets for quality improvement were identified. Future research will explore the impact of the NeoTree on quality of care and newborn survival

Protocol for an intervention development and pilot implementation evaluation study of an e-health solution to improve newborn care quality and survival in two low-resource settings, Malawi and Zimbabwe: Neotree.

INTRODUCTION: Every year 2.4 million deaths occur worldwide in babies younger than 28 days. Approximately 70% of these deaths occur in low-resource settings because of failure to implement evidence-based interventions. Digital health technologies may offer an implementation solution. Since 2014, we have worked in Bangladesh, Malawi, Zimbabwe and the UK to develop and pilot Neotree: an android app with accompanying data visualisation, linkage and export. Its low-cost hardware and state-of-the-art software are used to improve bedside postnatal care and to provide insights into population health trends, to impact wider policy and practice. METHODS AND ANALYSIS: This is a mixed methods (1) intervention codevelopment and optimisation and (2) pilot implementation evaluation (including economic evaluation) study. Neotree will be implemented in two hospitals in Zimbabwe, and one in Malawi. Over the 2-year study period clinical and demographic newborn data will be collected via Neotree, in addition to behavioural science informed qualitative and quantitative implementation evaluation and measures of cost, newborn care quality and usability. Neotree clinical decision support algorithms will be optimised according to best available evidence and clinical validation studies. ETHICS AND DISSEMINATION: This is a Wellcome Trust funded project (215742_Z_19_Z). Research ethics approvals have been obtained: Malawi College of Medicine Research and Ethics Committee (P.01/20/2909; P.02/19/2613); UCL (17123/001, 6681/001, 5019/004); Medical Research Council Zimbabwe (MRCZ/A/2570), BRTI and JREC institutional review boards (AP155/2020; JREC/327/19), Sally Mugabe Hospital Ethics Committee (071119/64; 250418/48). Results will be disseminated via academic publications and public and policy engagement activities. In this study, the care for an estimated 15 000 babies across three sites will be impacted. TRIAL REGISTRATION NUMBER: NCT0512707; Pre-results