{
  "abstract": "Introduction Breathlessness is a common cause of hospital admission globally and is associated with high mortality, particularly in low-income countries. In sub-Saharan Africa, there is a paucity of data on breathlessness, with existing data focused on individual diseases. There is a need for patient-centred approaches to understand interactions between multiple conditions to address population needs and inform health system responses. This multicentre prospective study in Malawi aimed to characterise the aetiologies, outcomes and biomarker accuracy for breathless patients.Methods Adults (aged ≥18 years) admitted to medical wards were consecutively recruited within 24 hours of hospital presentation and followed up for 1 year. Participants with breathlessness (defined as a composite of patient-reported shortness of breath; tachypnoea (respiratory rate ≥25/min); hypoxaemia (SpO 2 <94%) or treatment with oxygen) were systematically screened against internationally accepted diagnostic criteria. We estimated disease prevalence, survival, health-related quality of life and functional status. We also evaluated diagnostic accuracy of natriuretic peptides for heart failure, and procalcitonin (PCT) and C reactive peptide (CRP) for pneumonia.Results Of 751 participants, 44% (n=334) had breathlessness, and 316 underwent enhanced diagnostic screening. One-year mortality was higher in breathless patients (51% (157/307)) than those without (26% (100/385)); adjusted HR 1.8 (95% CI 1.4 to 2.3). We identified high prevalence and mortality of heart failure (35% (112/316) prevalence; 69% (75/109) 1-year mortality), anaemia (40% (126/316); 57% (70/122)), pneumonia (41% (131/316); 53% (68/129)) and tuberculosis (29% (91/316); 47% (41/87)). Most participants (63% (199/316)) had multiple conditions. Diagnostic accuracy (area under the curve) for heart failure was 0.89 (brain natriuretic peptide) and 0.88 (N-terminal pro-B-type natriuretic peptide); for pneumonia, CRP was 0.77 and PCT was 0.69.Discussion Breathlessness-related hospital admissions in Malawi are common, multifactorial and associated with poor survival. This study demonstrates that co-existing conditions are common, highlighting the limitation of single-disease-focused health system responses. Integrated care pathways with context-sensitive diagnostic and treatment approaches are urgently needed to improve survival.",
  "authors": [
    {
      "affiliations": [
        "Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK",
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi",
        "Queen Elizabeth Central Hospital, Blantyre, Malawi"
      ],
      "name": "Stephen A Spencer"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Florence Malowa"
    },
    {
      "affiliations": [
        "Queen Elizabeth Central Hospital, Blantyre, Malawi",
        "Kamuzu University of Health Sciences, Blantyre, Malawi"
      ],
      "name": "David McCarty"
    },
    {
      "affiliations": [
        "Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK"
      ],
      "name": "Elizabeth Joekes"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Jacob Phulusa"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Beatrice Chinoko"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Sylvester Kaimba"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Lucy Keyala"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Peter Mandala"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Mercy Mkandawire"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Albert Mukatipa"
    },
    {
      "affiliations": [
        "Queen Elizabeth Central Hospital, Blantyre, Malawi",
        "Kamuzu University of Health Sciences, Blantyre, Malawi"
      ],
      "name": "Mulinda Nyirenda"
    },
    {
      "affiliations": [
        "Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania"
      ],
      "name": "Hendry R Sawe"
    },
    {
      "affiliations": [
        "Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK"
      ],
      "name": "Sarah A White"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Marc Y R Henrion"
    },
    {
      "affiliations": [
        "Royal United Hospitals Bath NHS Foundation Trust, Bath, UK"
      ],
      "name": "Daniel X Augustine"
    },
    {
      "affiliations": [
        "Liverpool Centre for Cardiovascular Sciences, Liverpool John Moores University, Liverpool, UK"
      ],
      "name": "David Oxborough"
    },
    {
      "affiliations": [
        "Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK"
      ],
      "name": "Eve Worrall"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Felix Limbani"
    },
    {
      "affiliations": [
        "Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK"
      ],
      "name": "Paul Dark"
    },
    {
      "affiliations": [
        "Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK",
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi"
      ],
      "name": "Jamie Rylance"
    },
    {
      "affiliations": [
        "Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi",
        "Institute of Regeneration and Repair, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK"
      ],
      "name": "Stephen B Gordon"
    },
    {
      "affiliations": [
        "Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK"
      ],
      "name": "Ben Morton"
    },
    {
      "affiliations": [],
      "name": "On behalf of the Collaborators"
    }
  ],
  "title": "Acute breathlessness as a cause of hospitalisation in Malawi: a prospective, patient-centred study to evaluate causes and outcomes",
  "uid": "c5f0215d-96ad-5b31-b631-6825cc25d43c"
}