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1. Preparing for pandemics: a systematic review of pandemic influenza clinical management guidelines

Author

Ishmeala Rigby, Melina Michelen, Vincent Cheng, Andrew Dagens, Dania Dahmash, Samuel Lipworth, Eli Harriss, Erhui Cai, Valeria Balan, Alexandra Oti, Reena Joseph, Helen Groves, Peter Hart, Shevin Jacob, Lucille Blumberg, Peter W. Horby, and Louise Sigfrid

Subjects
Pandemic, Preparedness, Influenza, Clinical management guidelines, AGREE II, Supportive care, Medicine
Abstract

Abstract Background The COVID-19 pandemic has highlighted the importance of evidence-based clinical decision-making. Clinical management guidelines (CMGs) may help reduce morbidity and mortality by improving the quality of clinical decisions. This systematic review aims to evaluate the availability, inclusivity, and quality of pandemic influenza CMGs, to identify gaps that can be addressed to strengthen pandemic preparedness in this area. Methods Ovid Medline, Ovid Embase, TRIP (Turning Research Into Practice), and Guideline Central were searched systematically from January 2008 to 23rd June 2022, complemented by a grey literature search till 16th June 2022. Pandemic influenza CMGs including supportive care or empirical treatment recommendations were included. Two reviewers independently extracted data from the included studies and assessed their quality using AGREE II (Appraisal of Guidelines for Research & Evaluation). The findings are presented narratively. Results Forty-eight CMGs were included. They were produced in high- (42%, 20/48), upper-middle- (40%, 19/48), and lower-middle (8%, 4/48) income countries, or by international organisations (10%, 5/48). Most CMGs (81%, 39/48) were over 5 years old. Guidelines included treatment recommendations for children (75%, 36/48), pregnant women (54%, 26/48), people with immunosuppression (33%, 16/48), and older adults (29%, 14/48). Many CMGs were of low quality (median overall score: 3 out of 7 (range 1–7). All recommended oseltamivir; recommendations for other neuraminidase inhibitors and supportive care were limited and at times contradictory. Only 56% (27/48) and 27% (13/48) addressed oxygen and fluid therapy, respectively. Conclusions Our data highlights the limited availability of up-to-date pandemic influenza CMGs globally. Of those identified, many were limited in scope and quality and several lacked recommendations for specific at-risk populations. Recommendations on supportive care, the mainstay of treatment, were limited and heterogeneous. The most recent guideline highlighted that the evidence-base to support antiviral treatment recommendations is still limited. There is an urgent need for trials into treatment and supportive care strategies including for different risk populations. New evidence should be incorporated into globally accessible guidelines, to benefit patient outcomes. A ‘living guideline’ framework is recommended and further research into guideline implementation in different resourced settings, particularly low- and middle-income countries.

Published
2022
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2. Pathogen Detection Using Metagenomic Next-Generation Sequencing of Plasma Samples from Patients with Sepsis in Uganda

Author

Brian S. Grundy, Hardik Parikh, Shevin Jacob, Patrick Banura, Chris C. Moore, Jie Liu, and Eric R. Houpt

Subjects
human immunodeficiency virus, metagenomics, sepsis, sub-Saharan Africa, Microbiology, QR1-502
Abstract

ABSTRACT Metagenomic sequencing is a promising new method for pathogen detection. We aimed to detect pathogens from archived plasma using metagenomic sequencing in a previously well-characterized cohort of 254 predominantly HIV-infected patients with sepsis in Uganda. We used Illumina sequencing and the Chan Zuckerberg ID metagenomics platform to sequence and identify pathogens. On average, each plasma sample yielded 3,404,737 ± 2,201,997 reads (mean ± standard deviation), of which 220,032 ± 416,691 (6.3% ± 8.6%) were identified as nonhuman reads. Using a background model filter, 414 genus-specific pathogen identifications were found in the 254 samples. Nineteen pathogens were previously detected positive by quantitative PCR (qPCR), compared to sequencing, which demonstrated 30.2% sensitivity and 99.5% specificity. Sensitivity was higher for viral pathogens than nonviral pathogens (37% versus 5%). For example, HIV viremia was detected in 69% of samples using qPCR, and sequencing revealed 70% sensitivity and 92% specificity. There were 75 genus-specific potential pathogens identified by sequencing in this cohort, including hepatitis B and Epstein-Barr virus (EBV), among several others. qPCR showed a prevalence of hepatitis B and EBV viremia of 17% and 45%, respectively. In-hospital mortality was associated with a lower qPCR threshold cycle value for EBV (adjusted odds ratio, 0.85; P

Published
2023
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3. Pediatric post-discharge mortality in resource-poor countries: A protocol for an updated systematic review and meta-analysis.

Author

Maryum Chaudhry, Martina Knappett, Vuong Nguyen, Jessica Trawin, Nathan Kenya Mugisha, Jerome Kabakyenga, Elias Kumbakumba, Shevin Jacob, J Mark Ansermino, Niranjan Kissoon, and Matthew O Wiens

Subjects
Medicine, Science
Abstract

BackgroundMore than 50 countries, mainly in Sub-Saharan Africa and South Asia, are not on course to meet the neonatal and under-five mortality target set by the Sustainable Development Goals (SDGs) for the year 2030. One important, yet neglected, aspect of child mortality rates is deaths occurring during the post-discharge period. For children living in resource-poor countries, the rate of post-discharge mortality within the first several months after discharge is often as high as the rates observed during the initial admission period. This has generally been observed within the context of acute illness and has been closely linked to underlying conditions such as malnutrition, HIV, and anemia. These post-discharge mortality rates tend to be underreported and present a major oversight in the efforts to reduce overall child mortality. This review will explore recurrent illness following discharge through determination of rates of, and risk factors for, pediatric post-discharge mortality in resource-poor settings.MethodsEligible studies will be retrieved using MEDLINE, EMBASE, and CINAHL databases. Only studies with a post-discharge observation period of more than 7 days following discharge will be eligible for inclusion. Secondary outcomes will include post-discharge mortality relative to in-hospital mortality, overall readmission rates, pooled estimates of risk factors (e.g. admission details vs discharge factors, clinical vs social factors), pooled post-discharge mortality Kaplan-Meier survival curves, and outcomes by disease subgroups (e.g. malnutrition, anemia, general admissions). A narrative description of the included studies will be synthesized to categorize commonly affected patient population categories and a random-effects meta-analysis will be conducted to quantify overall post-discharge mortality rates at the 6-month time point.DiscussionPost-discharge mortality contributes to global child mortality rates with a greater burden of deaths occurring in resource-poor settings. Literature concentrated on child mortality published over the last decade has expanded to focus on the fatal outcomes of children post-discharge and associated risk factors. The results from this systematic review will inform current policy and interventions on the epidemiological burden of post-discharge mortality and morbidity following acute illness among children living in resource-poor settings.Systematic review registrationPROSPERO Registration ID: CRD42022350975.

Published
2023
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4. AGILE: a seamless phase I/IIa platform for the rapid evaluation of candidates for COVID-19 treatment: an update to the structured summary of a study protocol for a randomised platform trial letter

Author

Gareth O. Griffiths, Richard FitzGerald, Thomas Jaki, Andrea Corkhill, Helen Reynolds, Sean Ewings, Susannah Condie, Emma Tilt, Lucy Johnson, Mike Radford, Catherine Simpson, Geoffrey Saunders, Sara Yeats, Pavel Mozgunov, Olana Tansley-Hancock, Karen Martin, Nichola Downs, Izabela Eberhart, Jonathan W. B. Martin, Cristiana Goncalves, Anna Song, Tom Fletcher, Kelly Byrne, David G. Lalloo, Andrew Owen, Michael Jacobs, Lauren Walker, Rebecca Lyon, Christie Woods, Jennifer Gibney, Justin Chiong, Nomathemba Chandiwana, Shevin Jacob, Mohammed Lamorde, Catherine Orrell, Munir Pirmohamed, Saye Khoo, and on behalf of the AGILE investigators

Subjects
COVID-19, SARS-CoV-2, Randomised controlled trial, Platform study, Master protocol, Phase I/II, Bayesian, Medicine (General), R5-920
Abstract

Abstract Background There is an urgent unmet clinical need for the identification of novel therapeutics for the treatment of COVID-19. A number of COVID-19 late phase trial platforms have been developed to investigate (often repurposed) drugs both in the UK and globally (e.g. RECOVERY led by the University of Oxford and SOLIDARITY led by WHO). There is a pressing need to investigate novel candidates within early phase trial platforms, from which promising candidates can feed into established later phase platforms. AGILE grew from a UK-wide collaboration to undertake early stage clinical evaluation of candidates for SARS-CoV-2 infection to accelerate national and global healthcare interventions. Methods/design AGILE is a seamless phase I/IIa platform study to establish the optimum dose, determine the activity and safety of each candidate and recommend whether it should be evaluated further. Each candidate is evaluated in its own trial, either as an open label single arm healthy volunteer study or in patients, randomising between candidate and control usually in a 2:1 allocation in favour of the candidate. Each dose is assessed sequentially for safety usually in cohorts of 6 patients. Once a phase II dose has been identified, efficacy is assessed by seamlessly expanding into a larger cohort. AGILE is completely flexible in that the core design in the master protocol can be adapted for each candidate based on prior knowledge of the candidate (i.e. population, primary endpoint and sample size can be amended). This information is detailed in each candidate specific trial protocol of the master protocol. Discussion Few approved treatments for COVID-19 are available such as dexamethasone, remdesivir and tocilizumab in hospitalised patients. The AGILE platform aims to rapidly identify new efficacious and safe treatments to help end the current global COVID-19 pandemic. We currently have three candidate specific trials within this platform study that are open to recruitment. Trial registration EudraCT Number: 2020-001860-27 14 March 2020 ClinicalTrials.gov Identifier: NCT04746183 19 February 2021 ISRCTN reference: 27106947

Published
2021
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5. Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines

Author

Benjamin Silberberg, Stephen Aston, Selda Boztepe, Shevin Jacob, and Jamie Rylance

Subjects
Sepsis, Fluid therapy, Vasoconstrictor agents, Africa south of the Sahara, Practice guidelines as topic, Systematic review, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Background Sepsis guidelines are widely used in high-income countries and intravenous fluids are an important supportive treatment modality. However, fluids have been harmful in intervention trials in low-income countries, most notably in sub-Saharan Africa. We assessed the relevance, quality and applicability of available guidelines for the fluid management of adult patients with sepsis in this region. Methods We identified sepsis guidelines by systematic review with broad search terms, duplicate screening and data extraction. We included peer-reviewed publications with explicit relevance to sepsis and fluid therapy. We excluded those designed exclusively for specific aetiologies of sepsis, for limited geographic locations, or for non-adult populations. We used the AGREE II tool to assess the quality of guideline development, performed a narrative synthesis and used theoretical case scenarios to assess practical applicability to everyday clinical practice in resource-constrained settings. Results Published sepsis guidelines are heterogeneous in sepsis definition and in quality: 8/10 guidelines had significant deficits in applicability, particularly with reference to resource considerations in low-income settings. Indications for intravenous fluid were hypotension (8/10), clinical markers of hypoperfusion (6/10) and lactataemia (3/10). Crystalloids were overwhelmingly recommended (9/10). Suggested volumes varied; 5/10 explicitly recommended “fluid challenges” with reassessment, totalling between 1 L and 4 L during initial resuscitation. Fluid balance, including later de-escalation of therapy, was not specifically described in any. Norepinephrine was the preferred initial vasopressor (5/10), specifically targeted to MAP > 65 mmHg (3/10), with higher values suggested in pre-existing hypertension (1/10). Recommendations for guidelines were almost universally derived from evidence in high-income countries. None of the guidelines suggested any refinement for patients with malnutrition. Conclusions Widely used international guidelines contain disparate recommendations on intravenous fluid use, lack specificity and are largely unattainable in low-income countries given available resources. A relative lack of high-quality evidence from sub-Saharan Africa increases reliance on recommendations which may not be relevant or implementable.

Published
2020
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6. Proceedings from the 9th annual conference on the science of dissemination and implementation

Author

David Chambers, Lisa Simpson, Gila Neta, Ulrica von Thiele Schwarz, Antoinette Percy-Laurry, Gregory A. Aarons, Ross Brownson, Amanda Vogel, Shannon Wiltsey Stirman, Kenneth Sherr, Rachel Sturke, Wynne E. Norton, Allyson Varley, Cynthia Vinson, Lisa Klesges, Suzanne Heurtin-Roberts, M. Rashad Massoud, Leighann Kimble, Arne Beck, Claire Neely, Jennifer Boggs, Carmel Nichols, Wen Wan, Erin Staab, Neda Laiteerapong, Nathalie Moise, Ravi Shah, Susan Essock, Margaret Handley, Amy Jones, Jay Carruthers, Karina Davidson, Lauren Peccoralo, Lloyd Sederer, Todd Molfenter, Ashley Scudder, Sarah Taber-Thomas, Kristen Schaffner, Amy Herschell, Eva Woodward, Jeffery Pitcock, Mona Ritchie, JoAnn Kirchner, Julia E. Moore, Sobia Khan, Shusmita Rashid, Jamie Park, Melissa Courvoisier, Sharon Straus, Daniel Blonigen, Allison Rodriguez, Luisa Manfredi, Andrea Nevedal, Joel Rosenthal, David Smelson, Christine Timko, Nicole Stadnick, Jennifer Regan, Miya Barnett, Anna Lau, Lauren Brookman-Frazee, Erick Guerrero, Karissa Fenwick, Yinfei Kong, Gregory Aarons, Rebecca Lengnick-Hall, Benjamin Henwood, Nina Sayer, Craig Rosen, Robert Orazem, Brandy Smith, Lindsey Zimmerman, David Lounsbury, Rachel Kimerling, Jodie A. Trafton, Steven Lindley, Rahul Bhargava, Hal Roberts, Laura Gibson, Gabriel J. Escobar, Vincent Liu, Benjamin Turk, Arona Ragins, Patricia Kipnis, Ashley Ketterer Gruszkowski, Michael W. Kennedy, Emily Rentschler Drobek, Lior Turgeman, Aleksandra Sasha Milicevic, Terrence L. Hubert, Larissa Myaskovsky, Youxu C. Tjader, Robert J. Monte, Kathryn G. Sapnas, Edmond Ramly, Diane R Lauver, Christie M Bartels, Shereef Elnahal, Andrea Ippolito, Hillary Peabody, Carolyn Clancy, Randall Cebul, Thomas Love, Douglas Einstadter, Shari Bolen, Brook Watts, Vera Yakovchenko, Angela Park, William Lukesh, Donald R. Miller, David Thornton, Mari-Lynn Drainoni, Allen L. Gifford, Shawna Smith, Julia Kyle, Mark S Bauer, Daniel Eisenberg, Celeste Liebrecht, Michelle Barbaresso, Amy Kilbourne, Elyse Park, Giselle Perez, Jamie Ostroff, Sarah Greene, Michael Parchman, Brian Austin, Eric Larson, Stefanie Ferreri, Chris Shea, Megan Smith, Kea Turner, Jennifer Bacci, Kyle Bigham, Geoffrey Curran, Caity Frail, Cory Hamata, Terry Jankowski, Wendy Lantaff, Melissa Somma McGivney, Margie Snyder, Megan McCullough, Chris Gillespie, Beth Ann Petrakis, Ellen Jones, Carol VanDeusen Lukas, Adam Rose, Sarah J. Shoemaker, Jeremy Thomas, Benjamin Teeter, Holly Swan, Appathurai Balamurugan, Meghan Lane-Fall, Rinad Beidas, Laura Di Taranti, Sruthi Buddai, Enrique Torres Hernandez, Jerome Watts, Lee Fleisher, Frances Barg, Isomi Miake-Lye, Tanya Olmos, Emmeline Chuang, Hector Rodriguez, Gerald Kominski, Becky Yano, Stephen Shortell, Mary Hook, Linda Fleisher, Alexander Fiks, Katie Halkyard, Rachel Gruver, Emily Sykes, Kimberly Vesco, Kate Beadle, Joanna Bulkley, Ashley Stoneburner, Michael Leo, Amanda Clark, Joan Smith, Christopher Smyser, Maggie Wolf, Shamik Trivedi, Brian Hackett, Rakesh Rao, F. Sessions Cole, Rose McGonigle, Ann Donze, Enola Proctor, Amit Mathur, Emmanuela Gakidou, Stephen Gloyd, Carolyn Audet, Jose Salato, Sten Vermund, Rivet Amico, Stephanie Smith, Beatha Nyirandagijimana, Hildegarde Mukasakindi, Christian Rusangwa, Molly Franke, Giuseppe Raviola, Matthew Cummings, Elijah Goldberg, Savio Mwaka, Olive Kabajaasi, Adithya Cattamanchi, Achilles Katamba, Shevin Jacob, Nathan Kenya-Mugisha, J. Lucian Davis, Julie Reed, Rohit Ramaswamy, Gareth Parry, Sylvia Sax, Heather Kaplan, Keng-yen Huang, Sabrina Cheng, Susan Yee, Kimberly Hoagwood, Mary McKay, Donna Shelley, Gbenga Ogedegbe, Laurie Miller Brotman, Roman Kislov, John Humphreys, Gill Harvey, Paul Wilson, Robert Lieberthal, Colleen Payton, Mona Sarfaty, George Valko, Rendelle Bolton, Christine Hartmann, Nora Mueller, Sally K. Holmes, Barbara Bokhour, Sarah Ono, Benjamin Crabtree, Leah Gordon, William Miller, Bijal Balasubramanian, Leif Solberg, Deborah Cohen, Kate McGraw, Andrew Blatt, Demietrice Pittman, Helen Kales, Dan Berlowitz, Teresa Hudson, Christian Helfrich, Erin Finley, Ashley Garcia, Kristen Rosen, Claudina Tami, Don McGeary, Mary Jo Pugh, Jennifer Sharpe Potter, Krysttel Stryczek, David Au, Steven Zeliadt, George Sayre, Jennifer Leeman, Allison Myers, Jennifer Grant, Mary Wangen, Tara Queen, Alexandra Morshed, Elizabeth Dodson, Rachel Tabak, Ross C. Brownson, R. Chris Sheldrick, Thomas Mackie, Justeen Hyde, Laurel Leslie, Itzhak Yanovitzky, Matthew Weber, Nicole Gesualdo, Teis Kristensen, Cameo Stanick, Heather Halko, Caitlin Dorsey, Byron Powell, Bryan Weiner, Cara Lewis, Patricia Carreno, Kera Mallard, Tasoula Masina, Candice Monson, Taren Swindle, Zachary Patterson, Leanne Whiteside-Mansell, Rochelle Hanson, Benjamin Saunders, Sonja Schoenwald, Angela Moreland, Sarah Birken, Justin Presseau, David Ganz, Brian Mittman, Deborah Delevan, Jennifer N. Hill, Sara Locatelli, Gemmae Fix, Jeffrey Solomon, Sherri L. Lavela, Victoria Scott, Jonathan Scaccia, Kassy Alia, Brittany Skiles, Abraham Wandersman, Anne Sales, Megan Roberts, Amy Kennedy, Muin J. Khoury, Nina Sperber, Lori Orlando, Janet Carpenter, Larisa Cavallari, Joshua Denny, Amanda Elsey, Fern Fitzhenry, Yue Guan, Carol Horowitz, Julie Johnson, Ebony Madden, Toni Pollin, Victoria Pratt, Tejinder Rakhra-Burris, Marc Rosenman, Corrine Voils, Kristin Weitzel, Ryanne Wu, Laura Damschroder, Christine Lu, Rachel Ceccarelli, Kathleen M. Mazor, Ann Wu, Alanna Kulchak Rahm, Adam H. Buchanan, Marci Schwartz, Cara McCormick, Kandamurugu Manickam, Marc S. Williams, Michael F. Murray, Ngoc-Cam Escoffery, Erin Lebow-Skelley, Hallie Udelson, Elaine Böing, Maria E. Fernandez, Richard J. Wood, Patricia Dolan Mullen, Jenita Parekh, Valerie Caldas, Elizabeth A. Stuart, Shalynn Howard, Gilo Thomas, Jacky M. Jennings, Jennifer Torres, Christine Markham, Ross Shegog, Melissa Peskin, Stephanie Craig Rushing, Amanda Gaston, Gwenda Gorman, Cornelia Jessen, Jennifer Williamson, Dianne Ward, Amber Vaughn, Ellie Morris, Stephanie Mazzucca, Regan Burney, Shoba Ramanadhan, Sara Minsky, Vilma Martinez-Dominguez, Kasisomayajula Viswanath, Megan Barker, Myra Fahim, Arezoo Ebnahmady, Rosa Dragonetti, Peter Selby, Margaret Farrell, Jordan Tompkins, Wynne Norton, Kaelin Rapport, Margaret Hargreaves, Rebekka Lee, Gina Kruse, Charles Deutsch, Emily Lanier, Ashley Gray, Aaron Leppin, Lori Christiansen, Karen Schaepe, Jason Egginton, Megan Branda, Charlene Gaw, Sara Dick, Victor Montori, Nilay Shah, Ariella Korn, Peter Hovmand, Karen Fullerton, Nancy Zoellner, Erin Hennessy, Alison Tovar, Ross Hammond, Christina Economos, Christi Kay, Julie Gazmararian, Emily Vall, Patricia Cheung, Padra Franks, Shannon Barrett-Williams, Paul Weiss, Erica Hamilton, Luana Marques, Louise Dixon, Emily Ahles, Sarah Valentine, Derri Shtasel, Ruben Parra-Cardona, Mary Northridge, Rucha Kavathe, Jennifer Zanowiak, Laura Wyatt, Hardayal Singh, Nadia Islam, Madalena Monteban, Darcy Freedman, Kimberly Bess, Colleen Walsh, Kristen Matlack, Susan Flocke, Heather Baily, Samantha Harden, NithyaPriya Ramalingam, VCE Physical Activity Leadership Team, Rachel Gold, Erika Cottrell, Celine Hollombe, Katie Dambrun, Arwen Bunce, Mary Middendorf, Marla Dearing, Stuart Cowburn, Ned Mossman, Gerry Melgar, Suellen Hopfer, Michael Hecht, Anne Ray, Michelle Miller-Day, Rhonda BeLue, Greg Zimet, Eve-Lynn Nelson, Sandy Kuhlman, Gary Doolittle, Hope Krebill, Ashley Spaulding, Theodore Levin, Michael Sanchez, Molly Landau, Patricia Escobar, Nadia Minian, Aliya Noormohamed, Laurie Zawertailo, Dolly Baliunas, Norman Giesbrecht, Bernard Le Foll, Andriy Samokhvalov, Zachary Meisel, Daniel Polsky, Bruce Schackman, Julia Mitchell, Kaitlyn Sevarino, Sarah Gimbel, Moses Mwanza, Marie Paul Nisingizwe, Catherine Michel, Lisa Hirschhorn, Mahrukh Choudhary, Della Thonduparambil, Paul Meissner, Hilary Pinnock, Melanie Barwick, Christopher Carpenter, Sandra Eldridge, Gonzalo Grandes-Odriozola, Chris Griffiths, Jo Rycroft-Malone, Elizabeth Murray, Anita Patel, Aziz Sheikh, Stephanie J. C. Taylor, Martin Guilliford, Gemma Pearce, Diane Korngiebel, Kathleen West, Wylie Burke, Peggy Hannon, Jeffrey Harris, Kristen Hammerback, Marlana Kohn, Gary K. C. Chan, Riki Mafune, Amanda Parrish, Shirley Beresford, K. Joanne Pike, Rachel Shelton, Lina Jandorf, Deborah Erwin, Thana-Ashley Charles, Laura-Mae Baldwin, Brooke Ike, Jacqueline Fickel, Jason Lind, Diane Cowper, Marguerite Fleming, Amy Sadler, Melinda Dye, Judith Katzburg, Michael Ong, Sarah Tubbesing, Molly Simmons, Autumn Harnish, Sonya Gabrielian, Keith McInnes, Jeffrey Smith, John Ferrand, Elisa Torres, Amy Green, Angela R. Bradbury, Linda J. Patrick-Miller, Brian L. Egleston, Susan M. Domchek, Olufunmilayo I. Olopade, Michael J. Hall, Mary B. Daly, Generosa Grana, Pamela Ganschow, Dominique Fetzer, Amanda Brandt, Rachelle Chambers, Dana F. Clark, Andrea Forman, Rikki S. Gaber, Cassandra Gulden, Janice Horte, Jessica Long, Terra Lucas, Shreshtha Madaan, Kristin Mattie, Danielle McKenna, Susan Montgomery, Sarah Nielsen, Jacquelyn Powers, Kim Rainey, Christina Rybak, Christina Seelaus, Jessica Stoll, Jill Stopfer, Xinxin Shirley Yao, Michelle Savage, Edward Miech, Teresa Damush, Nicholas Rattray, Jennifer Myers, Barbara Homoya, Kate Winseck, Carrie Klabunde, Deb Langer, Avi Aggarwal, Elizabeth Neilson, Lara Gunderson, Marla Gardner, Liam O’Sulleabhain, and Candyce Kroenke

Subjects
Medicine (General), R5-920
Published
2017
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7. Facilitating high quality acute care in resource-constrained environments: Perspectives of patients recovering from sepsis, their caregivers and healthcare workers in Uganda and Malawi

Author

FELIX LIMBANI and Shevin Jacob

Abstract

Sepsis is a major global health problem, especially in sub-Saharan Africa. Improving patient care requires that healthcare providers understand patients’ priorities and provide quality care within the confines of the context they work. We report the perspectives of patients, caregivers and healthcare workers regarding care quality for patients admitted for sepsis to public hospitals in Uganda and Malawi. This qualitative descriptive study in two hospitals included face-to face semi-structured interviews with purposively selected patients recovering from sepsis, their caregivers and healthcare workers. In both Malawi and Uganda, sepsis care often occurred in resource-constrained environments which undermined healthcare workers’ capacity to deliver safe, consistent and accessible care. Constraints included limited space, strained; water, sanitation and hygiene (WASH) amenities and practices, inadequate human and material resources and inadequate provision for basic needs including nutrition. Heavy workloads for healthcare workers strained relationships, led to poor communication and reduced engagement with patients and caregivers. These consequences were exacerbated by understaffing which affected handover and continuity of care. All groups (healthcare workers, patients and caregivers) reported delays in care due to long queues and lack of compliance with procedures for triage, treatment, stabilization and monitoring due to a lack of expertise, supervision and context-specific sepsis management guidelines. Quality sepsis care relies on effective severity-based triaging, rapid treatment of emergencies and individualised testing to confirm diagnosis and monitoring. Hospitals in resource-constrained systems contend with limitations in key resources, including for space, staff, expertise, equipment and medicines, in turn contributing to gaps in areas such as WASH and effective care delivery, as well as communication and other relational aspects of care. These limitations are the predominant challenges to achieving high quality care.

Published
2022
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12. Additional file 1: Appendix S1. of A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda

Author

Cummings, Matthew, Goldberg, Elijah, Savio Mwaka, Kabajaasi, Olive, Vittinghoff, Eric, Adithya Cattamanchi, Achilles Katamba, Kenya-Mugisha, Nathan, Shevin Jacob, and J. Lucian Davis

Abstract

Pre-training facility assessment tool. Appendix S2. Quick Check + hospital assessment report of existing severe illness practices. Table S1. Characteristics of inpatient health facilities participating in SIMS intervention. Table S2. Diagnostic criteria for severe illness conditions covered in Quick Check + training program, as defined by the World Health Organization District Clinician Manual. Table S3a. Barriers to executing target behaviors*, as documented by hospital staff while formulating implementation plans and placed into COM-B domains. Table S3b. Intervention functions targeting identified barriers and facilitators as defined in the Behavioral Change Wheel framework. Table S4a Between-site variation in vital sign collection before and after SIMS introduction, by site. Table S4b. Between-site variation in impact of SIMS on vital sign collection, by vital sign. Figure S1. Diagram illustrating the conceptual model based on components of the COM-B model that was utilized to develop the SIMS intervention. Figure S2. Staggered, pre-post quasi-experimental study design utilized for implementation of SIMS intervention. Baseline period indicates time period following Quick Check + training and before SIMS intervention. Intervention period indicates time period during which SIMS intervention was implemented. Figure S3. Flow diagram for patients included in study (DOCX 607Â kb)

Published
2017
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13. Proceedings of the 8th Annual Conference on the Science of Dissemination and Implementation

Author

Lina Jandorf, Janice Horte, Claire Neely, Christine Hartmann, Jennifer Regan, Lior Turgeman, Laura Wyatt, Avi Aggarwal, Elizabeth Murray, Susan Montgomery, Anne Ray, William Lukesh, Susan Yee, Keng-yen Huang, William L. Miller, Terry Jankowski, Anne E. Sales, Samantha M. Harden, Alexandra B. Morshed, George Valko, Julie Gazmararian, Kristen Schaffner, Marie Paul Nisingizwe, Amy Sadler, Heather Kaplan, Celeste Liebrecht, Jennifer Sharpe Potter, Helen Kales, M. Rashad Massoud, Caity Frail, Christian Rusangwa, Candice Monson, Bernard Le Foll, Gemmae Fix, Justin Presseau, George Sayre, Nicholas A. Rattray, Rebekka Lee, Arne Beck, Vincent Liu, Chris Griffiths, Megan Barker, Thomas Love, Leanne Whiteside-Mansell, Ross Shegog, Susan A. Flocke, Laurie Miller Brotman, Jeffery Pitcock, Moses Mwanza, Kera Mallard, Don McGeary, Rinad S. Beidas, Tara Queen, Thana-Ashley Charles, Toni Pollin, Jennifer Zanowiak, Julie Johnson, Carrie Klabunde, Wendy Lantaff, Martin Guilliford, Sabrina Cheng, Elyse Park, Mary McKay, Patricia Cheung, Marla Gardner, Suellen Hopfer, Julie E Reed, Jamie Park, Sarah M. Nielsen, Andrea Forman, Paul Meissner, Brittany Skiles, Steven B. Zeliadt, Shannon Wiltsey Stirman, Christina D. Economos, Amanda Clark, Rachel Kimerling, Katie Dambrun, Leah Gordon, Wen Wan, Krysttel Stryczek, Shari Bolen, Marc Rosenman, Kimberly K Vesco, Joel Rosenthal, Mona Sarfaty, Lara Gunderson, Hardayal Singh, Ann Donze, Ross A. Hammond, Catherine Michel, Stephanie Taylor, David Au, Rakesh Rao, Chris Shea, Christine Markham, David Smelson, Mary Northridge, K. Joanne Pike, Terra Lucas, Sherri L. Lavela, Mary Wangen, Appathurai Balamurugan, Hope Krebill, Daniel Blonigen, Roman Kislov, Edward J. Miech, Peggy A. Hannon, Myra Fahim, Mary Jo Pugh, Ross C. Brownson, Erika Cottrell, Emmanuela Gakidou, Paul Weiss, Kathryn G. Sapnas, Padra Franks, Shereef Elnahal, Margaret Hargreaves, Candyce Kroenke, Sandra Eldridge, Charles Deutsch, Elizabeth A. Dodson, Mona J. Ritchie, Jennifer Leeman, Barbara Bokhour, Paul Wilson, Christina Seelaus, Gina Kruse, Margaret Handley, Rachelle Chambers, Emily Vall, Norman Giesbrecht, Brian L. Egleston, Ariella R. Korn, Melissa Somma McGivney, Della Thonduparambil, Valerie Caldas, Maggie Wolf, Ashley Stoneburner, David A. Ganz, Patricia Dolan Mullen, Kaelin Rapport, Stephen M. Shortell, Teresa Hudson, John Ferrand, Sarah Ono, Jerome Watts, Allison Rodriguez, Ngoc-Cam Escoffery, Rose McGonigle, Ebony Madden, Donna Shelley, Rachel Sturke, Hillary Peabody, Ned Mossman, Giuseppe Raviola, J. Lucian Davis, Ashley Gray, Antoinette Percy-Laurry, Keith McInnes, Ashley Garcia, Nicole Gesualdo, Benjamin Saunders, Jacqueline J. Fickel, Nilay Shah, Barbara Homoya, Olive Kabajaasi, Amy Kilbourne, Aliya Noormohamed, John Humphreys, Sonya Gabrielian, Jennifer Williamson, Frances K. Barg, Thomas Mackie, Jessica Stoll, Ruben Parra-Cardona, Douglas Einstadter, Neda Laiteerapong, Gary Doolittle, Muin J. Khoury, Nadia Minian, Andrew N Blatt, Sylvia Sax, Edmond Ramly, Arezoo Ebnahmady, Achilles Katamba, Amit Mathur, Celine Hollombe, Christopher Smyser, Brook Watts, Nina Sperber, Sarah Birken, Karina Davidson, Jeffrey Solomon, Rosa Dragonetti, Fern Fitzhenry, Leif Solberg, Megan McCullough, Nina Sayer, Michelle Savage, Ashley Ketterer Gruszkowski, Linda Patrick-Miller, Molly Franke, Nora Mueller, Rachel G. Tabak, Elizabeth Neilson, Tejinder Rakhra-Burris, Laura-Mae Baldwin, Peter Selby, Hal Roberts, F. Sessions Cole, Gerry Melgar, Dianne Ward, Ellie Morris, Jamie Ostroff, Kimberly Hoagwood, Stephanie Mazzucca, Victoria Scott, Katie Halkyard, Jason Egginton, Amy Herschell, Nadia Islam, Danielle McKenna, Erin Lebow-Skelley, Richard J. Wood, Michael F. Murray, Jordan Tompkins, Aleksandra Sasha Milicevic, Lisa R. Hirschhorn, Jo Rycroft-Malone, David W. Lounsbury, Kathleen West, Tanya Olmos, Cassandra Gulden, Shalynn Howard, Stephanie Craig Rushing, Sten Vermund, Margaret M. Farrell, Dominique Fetzer, Linda Fleisher, Lisa Simpson, Michael J. Hall, Lisa M Klesges, Marc S. Williams, Karen Schaepe, Allyson Varley, Wynne E. Norton, Julia Kyle, Rivet Amico, Emily Ahles, Bruce R. Schackman, Erin P. Finley, Kristin Weitzel, Shevin Jacob, Rikki S. Gaber, Pamela Ganschow, Joshua Denny, Victor Montori, JoAnn Kirchner, Lauren Brookman-Frazee, Rhonda BeLue, Zachary Patterson, Jennifer Boggs, Riki Mafune, Sarah J. Shoemaker, Kate Winseck, Joan Smith, Marci Schwartz, Gabriel J. Escobar, Shannon Barrett-Williams, Gary K. C. Chan, Arona Ragins, Beth Ann Petrakis, Liam O’Sulleabhain, David Thornton, Cynthia Vinson, Jacky M. Jennings, Rucha Kavathe, Enrique Torres Hernandez, Elijah Goldberg, Patricia Carreno, Gill Harvey, Nathan Kenya-Mugisha, Brandy Smith, Demietrice Pittman, Enola K. Proctor, Angela Moreland, Kasisomayajula Viswanath, Adam Rose, Jennifer Bacci, Sarah Tubbesing, Kenneth Sherr, Emily Sykes, Shoba Ramanadhan, Nicole A. Stadnick, Amanda Brandt, Abraham Wandersman, Chris Gillespie, R. Chris Sheldrick, Amy Kennedy, Sara Dick, Carolyn M. Clancy, Savio Mwaka, Adithya Cattamanchi, Mahrukh Choudhary, Sruthi Buddai, Mark S Bauer, Generosa Grana, Shamik Trivedi, Gwenda Gorman, Deb Langer, Karissa Fenwick, Darcy A. Freedman, Jason Lind, Cara C. Lewis, Steven Lindley, Deborah O. Erwin, Melissa Peskin, Kristen D. Rosen, Terrence L. Hubert, Michael Ong, Aziz Sheikh, Justeen Hyde, Zachary F. Meisel, Claudina Tami, Greg Zimet, Jennifer Grant, Gerald F. Kominski, Jessica M. Long, Allison Myers, Chris Carpenter, Rachel Ceccarelli, Marla Dearing, Sharon Straus, Stephanie Smith, Michael A. Sanchez, Angela Park, Ellen Jones, Luisa Manfredi, Ravi Shah, Jacquelyn Powers, Cara McCormick, Shusmita Rashid, Victoria Pratt, Miya L. Barnett, Michael Parchman, Elaine Böing, Suzanne Heurtin-Roberts, Anita Patel, Christine Lu, Christi Kay, Jeremy Thomas, Craig Rosen, Gbenga Ogedegbe, Amanda T. Parrish, Diane R Lauver, Lori Orlando, Brian S. Mittman, Hallie Udelson, Rachel Gold, Erica Hamilton, José Salato, Youxu C. Tjader, Benjamin Turk, Giselle Perez, Amber Vaughn, Jeffrey R. Smith, Eric R. Larson, Rohit Ramaswamy, Colleen Payton, Jodie A. Trafton, Elisa M. Torres, Cameo Stanick, Bryan J. Weiner, Beatha Nyirandagijimana, Rachel C. Shelton, Rebecca Lengnick-Hall, Michael W. Kennedy, Madalena Monteban, Megan Roberts, Laurel Leslie, Autumn Harnish, Ann Wu, Janet Carpenter, Alexander Fiks, Carol R. Horowitz, Michael Hecht, Andriy V. Samokhvalov, Amanda Gaston, Olufunmilayo I. Olopade, Elizabeth A. Stuart, Dan Berlowitz, Matthew Weber, Amanda Vogel, Yinfei Kong, Rochelle Hanson, Lee Fleisher, Stephen Gloyd, Jay Carruthers, Melissa Courvoisier, Kim Rainey, Carmel Nichols, Christie M Bartels, Gregory A. Aarons, Kristin Mattie, Jonathan Scaccia, Vilma Martinez-Dominguez, Charlene Gaw, Christina Rybak, Nancy Zoellner, Leighann Kimble, Xinxin Shirley Yao, Kandamurugu Manickam, Caitlin Dorsey, Nathalie Moise, Marguerite Fleming, Meghan Lane-Fall, Michael Leo, Carolyn Audet, Stefanie Ferreri, Laura J. Damschroder, Kate McGraw, Colleen Walsh, Ross Brownson, Lindsey Zimmerman, Teresa M. Damush, Lori Christiansen, Hildegarde Mukasakindi, Mary B. Daly, Itzhak Yanovitzky, Laura Di Taranti, Mary Middendorf, Ashley Scudder, Diane Korngiebel, Kimberly Bess, Sarah Valentine, Erick G. Guerrero, Jennifer N. Hill, Sally K. Holmes, Hector P. Rodriguez, Sarah Greene, Joanna Bulkley, Theodore Levin, Cory Hamata, Michelle Barbaresso, Melanie Barwick, Margie Snyder, Sonja K. Schoenwald, Sara Locatelli, Jeffrey R. Harris, Laurie Zawertailo, Adam H. Buchanan, Erin Staab, Isomi Miake-Lye, Emily Lanier, Eva Woodward, David A. Chambers, Dolly Baliunas, Rachel Gruver, Amanda Elsey, Rahul Bhargava, Amy E. Green, Emmeline Chuang, Larissa Myaskovsky, Gemma Pearce, Megan Smith, Melinda Dye, Emily Rentschler Drobek, Lauren Peccoralo, Louise Dixon, Kassy Alia, Daniel Polsky, NithyaPriya Ramalingam, Byron J. Powell, Taren Swindle, Molly M. Simmons, Derri Shtasel, Brian Hackett, Lloyd Sederer, Michelle Miller-Day, Tasoula Masina, Kathleen M. Mazor, Gilo Thomas, Andrea Nevedal, Kaitlyn Sevarino, Julia E. Moore, Susan Essock, Patricia Kipnis, Gila Neta, Kyle Bigham, Christian Helfrich, Peter Hovmand, Sarah Gimbel, Luana Marques, Rendelle Bolton, Yue Guan, Benjamin Teeter, Angela R. Bradbury, Kristen Hammerback, Susan M. Domchek, Heather Baily, Dana F. Clark, Geoffrey M. Curran, Randall Cebul, Anna S. Lau, Shirley Beresford, Larisa Cavallari, Gonzalo Grandes-Odriozola, Eve-Lynn Nelson, Matthew Cummings, Ashley Spaulding, Bijal Balasubramanian, Brooke Ike, Arwen Bunce, Deborah J. Cohen, Jennifer Torres, Heather Halko, Karen Fullerton, Erin Hennessy, Benjamin Crabtree, Carol VanDeusen Lukas, Shawna Smith, Todd Molfenter, Gareth Parry, Kea Turner, Laura Gibson, Patricia Escobar, Becky Yano, Sobia Khan, Shreshtha Madaan, Teis Kristensen, Stuart Cowburn, Allen L. Gifford, Judith Katzburg, Kate Beadle, Maria E. Fernandez, Hilary Pinnock, Alanna Kulchak Rahm, Robert Lieberthal, Sarah Taber-Thomas, Daniel Eisenberg, Regan Burney, Amy Jones, Andrea Ippolito, Donald R. Miller, Christine Timko, Deborah Delevan, Marlana Kohn, Sara Minsky, Wylie Burke, Ulrica von Thiele Schwarz, Megan E. Branda, Alison Tovar, Corrine Voils, Kristen Matlack, Holly Swan, Vera Yakovchenko, Brian Austin, Benjamin Henwood, Mari-Lynn Drainoni, R. Ryanne Wu, Sandy Kuhlman, Jenita Parekh, Jennifer Myers, Aaron Leppin, Julia Mitchell, Robert J. Monte, Cornelia Jessen, Robert Orazem, Diane Cowper, Mary Hook, Jill Stopfer, and Molly Landau

Subjects
medicine.medical_specialty, education.field_of_study, business.industry, Health Policy, Public health, Population, Public Health, Environmental and Occupational Health, Health services research, Library science, Health Informatics, General Medicine, Population health, Health equity, 3. Good health, 03 medical and health sciences, 0302 clinical medicine, Community health, Health care, medicine, 030212 general & internal medicine, business, education, 030217 neurology & neurosurgery, Health policy
Abstract

A1 Introduction to the 8th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health David Chambers1, Lisa Simpson2 1Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD, 20850, USA; 2AcademyHealth, Washington, DC, 20036, USA For the second year in a row, we are pleased to be able to share the proceedings of the Annual Conference on the Science of Dissemination and Implementation in Health, a large meeting reflecting the expanding and evolving research field that seeks to optimize the use of evidence, interventions, and tools from health research within the myriad of settings where people receive health care, make health-related decisions, and increase knowledge of influences on the health of the population. We once again benefitted from a strong partnership, co-led by AcademyHealth and the National Institutes of Health (NIH), with co-sponsorship from the Agency for Healthcare Research and Quality (AHRQ), the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation (RWJF), the US Department of Veterans Affairs (VA), and the WT Grant Foundation. In addition, we benefitted from the collaboration of staff from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). NIH and AcademyHealth again co-led the program planning committee, which focused on the development of the plenary sessions, and convened a scientific advisory panel to suggest speakers and advise on the overall conference development. The planning committee identified four key areas around which to focus the plenary panels and keynote address. Dr. America Bracho, M.D., M.P.H., Executive Director of Latino Health Access in Orange County, California, spoke about the opportunities for implementation science to inform efforts to improve community health and engage underserved populations. The three plenary panels each focused on a significant future direction for dissemination and implementation (D & I) research: the interface between D&I science and population health, emerging opportunities for global implementation science, and the challenges around implementation of precision medicine. The plenary sessions were complemented by facilitated lunchtime discussions on the same three topics, which offered participants an opportunity to identify key research questions for each and brainstorm next steps. Synopses of the lunchtime discussions are included in this supplement. Given the overwhelming success of the 2014 conference and the large number of abstracts received in 2014 (660), the program planning committee identified eight program tracks for abstract submitters to respond to, and through which the concurrent sessions of the conference would be organized. These tracks—Behavioral Health, Big Data and Technology for Dissemination and Implementation Research, Clinical Care Settings, Global Dissemination and Implementation, Promoting Health Equity and Eliminating Disparities, Health Policy Dissemination and Implementation, Prevention and Public Health, and Models, Measures and Methods— were designed to enable conference participants to follow a consistent theme across the multiple sessions of the conference and form the structure of this supplement. The call for abstracts, including individual paper presentations, individual posters and panel presentations, resulted in 515 submissions, spread across the eight thematic tracks. Over one hundred reviewers devoted their time to ensuring a comprehensive and expert review, and reviews were conducted within each track and coordinated by the track leads. For the final program, 64 oral presentations, 12 panels, and 263 posters were presented over the two-day meeting. Slides for the oral presentations and panels (with the agreement of the authors) were posted on the conference website (http://diconference.academyhealth.org/archives/2015archives) and all abstracts were included on the conference webapp (https://academyhealth.confex.com/academyhealth/2015di/meetingapp.cgi). This supplement has compiled the abstracts for presented papers, panel sessions, and lunchtime discussions from the 8th Annual Meeting on the Science of Dissemination and Implementation in Health: Optimizing Personal and Population Health. We are pleased to have the abstracts from the conference together in one volume once again, and look forward to the 9th Annual meeting, scheduled for December in Washington, D.C.

Published
2016
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14. Convalescent Plasma for Ebola Virus Disease

Author

John Dye, Thierry Burnouf, Tom Fletcher, Shevin Jacob, Tansy Edwards, Jose Arribas, ESTHER Phase 2 Project (INT 108), Lux-Development SA (LuxDev), University of Bristol [Bristol], Institut Hospitalier Universitaire Méditerranée Infection (IHU Marseille), Emergence des Pathologies Virales (EPV), Institut de Recherche pour le Développement (IRD)-Aix Marseille Université (AMU)-Assistance Publique - Hôpitaux de Marseille (APHM)-Institut National de la Santé et de la Recherche Médicale (INSERM), Etablissement Français du Sang - Alpes-Méditerranée (EFS - Alpes-Méditerranée), and Etablissement Français du Sang

Subjects
Male, Convalescent plasma, MEDLINE, Blood Component Transfusion, Disease, 030204 cardiovascular system & hematology, medicine.disease_cause, 03 medical and health sciences, Plasma, 0302 clinical medicine, MESH: Pregnancy, Pregnancy, Medicine, Humans, 030212 general & internal medicine, MESH: Plasma, ComputingMilieux_MISCELLANEOUS, Ebola virus, MESH: Humans, business.industry, General Medicine, Hemorrhagic Fever, Ebola, medicine.disease, Virology, MESH: Male, MESH: Blood Component Transfusion, Immunology, MESH: Hemorrhagic Fever, Ebola, [SDV.MP.VIR]Life Sciences [q-bio]/Microbiology and Parasitology/Virology, Female, business, MESH: Female
Abstract

International audience

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15. Additional file 1: Appendix S1. of A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda

Author

Cummings, Matthew, Goldberg, Elijah, Savio Mwaka, Kabajaasi, Olive, Vittinghoff, Eric, Adithya Cattamanchi, Achilles Katamba, Kenya-Mugisha, Nathan, Shevin Jacob, and J. Lucian Davis

Subjects
3. Good health
Abstract

Pre-training facility assessment tool. Appendix S2. Quick Check + hospital assessment report of existing severe illness practices. Table S1. Characteristics of inpatient health facilities participating in SIMS intervention. Table S2. Diagnostic criteria for severe illness conditions covered in Quick Check + training program, as defined by the World Health Organization District Clinician Manual. Table S3a. Barriers to executing target behaviors*, as documented by hospital staff while formulating implementation plans and placed into COM-B domains. Table S3b. Intervention functions targeting identified barriers and facilitators as defined in the Behavioral Change Wheel framework. Table S4a Between-site variation in vital sign collection before and after SIMS introduction, by site. Table S4b. Between-site variation in impact of SIMS on vital sign collection, by vital sign. Figure S1. Diagram illustrating the conceptual model based on components of the COM-B model that was utilized to develop the SIMS intervention. Figure S2. Staggered, pre-post quasi-experimental study design utilized for implementation of SIMS intervention. Baseline period indicates time period following Quick Check + training and before SIMS intervention. Intervention period indicates time period during which SIMS intervention was implemented. Figure S3. Flow diagram for patients included in study (DOCX 607Â kb)

16. Additional file 1: of Ebola virus disease and critical illness

Author

Leligdowicz, Aleksandra, Fischer, William, Uyeki, Timothy, Fletcher, Thomas, Adhikari, Neill, Portella, Gina, Francois Lamontagne, Clement, Christophe, Shevin Jacob, Rubinson, Lewis, Vanderschuren, Abel, Hajek, Jan, Murthy, Srinivas, Ferri, Mauricio, Crozier, Ian, Elhadj Ibrahima, Marie-Claire Lamah, Schieffelin, John, Brett-Major, David, Bausch, Daniel, Shindo, Nikki, Chan, Adrienne, O’Dempsey, Tim, Mishra, Sharmistha, Jacobs, Michael, Dickson, Stuart, G. Lyon, and Fowler, Robert

Subjects
3. Good health
Abstract

Weblink references for Tables 1â 3. (DOCX 124 kb)

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