Browsing by Author "Thielman, Nathan"

Background: The COVID-19 pandemic amplified disparities experienced by children in immigrant and refugee families (CIRF). The pandemic coincided with a recognition that proactively screening and addressing social risk drivers is an efficacious population health intervention. We used the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework to set up a program to screen for social risks drivers at a Federally Qualified Health Center (FQHC). The study sought to demonstrate to what extent the proactive outreach program would a) capture at-risk persons and b) facilitate linkage of identified persons to community resources. We sought to c) quantify social needs among CIRF and d) understand whether addressing social risk drivers would lead to caregivers perceiving an improvement in their child’s health. Lastly, we sought to e) elucidate the experiences with and preferences of families in regard to screening efforts. Methods: The study was conducted at the Lincoln Community Health Center in Durham, North Carolina. Eligible participants were ages 0-5, non-English speaking, and were seen at the clinic within the last 2 years. A care coordinator reached out to the guardians of eligible children for baseline screening. Participants with social needs received referral placement and navigation support. We looked at the number of baseline questionnaires completed, linkage rates and resolution of social needs as well as perceptions of SDOH screening and perceived changes in child’s health using descriptive and univariate statistics. Results: We attempted to contact 342 guardians; to date, we did not reach 85 (24.85%) participants and 21 (6.14%) have incomplete outreach. 212 (61.99%) participants were enrolled and completed baseline screening. Most participants had at least one social need. Of the 212 individuals enrolled, the 39 who completed the intervention (100%) indicated that the calls helped them to gain a better understanding of community resources. When asked who they would be most comfortable talking with about their social needs, the majority indicated a case manager in person (34, 89.5%) or over the phone (36, 94.74%). When asked about what characteristics were important to them when considering who they might speak with about their social needs, 36 (92.1%) selected language and 22 (57.9%) indicated that cultural affiliation was important. The impact of the intervention on the perception of child’s health was unable to be quantified due to a small sample size. Conclusion: Our findings illustrate the burden of social risk drivers experienced by CIRF and demonstrate the capacity of a proactive outreach SDOH screening program to meet the needs of CIRF served by a FQHC. It is our hope that this screening tool and proactive outreach program can be used as a model to better identify and address the social needs of CIRF and to thus enhance health outcomes and population health.

Objectives: To compare measures of health and health quality between Orphans and Vulnerable Children (OVC) in different living arrangements-- institutional and community care; and to correlate different measures of OVC health and health quality using clinical, laboratory and quality of life instruments.

Design: Cross-sectional study.

Setting: Two rural districts (sites) in East Africa, Bungoma in Kenya, and Kilimanjaro in Tanzania.

Participants: 77 male and 45 female OVC aged 16-18 years (N=122). Participants, who had attained a minimum age of 16 at the date of interview, were selected from the larger sample of OVC in the Positive Outcomes for Orphans (POFO) study. POFO, a longitudinal study in five less wealthy countries that started in 2006, obtained its sample through cluster randomization.

Methods: To obtain self-ratings of OVC physical health, OVC responded to an interviewer administered SF-36 questionnaire, a multipurpose generic measure of health status. A neutral examiner then measured OVC physical health using 4 clinical variables: a physical health examination, body mass index, hemoglobin level, and the Harvard physical fitness score.

Main Outcome Measures: SF-36 scores presented as a two component score- the physical health and mental health composite sub-scores. For physical health, normal findings for age were considered as meeting the threshold for good physical health.

Results: Of the 122 OVC, 89 (73%) lived in the community while 33 (27%) lived in institutional settings. For the SF-36, the mean physical composite score for the entire study population was 50.6 (SD=6.2). Mean body mass index (BMI) was 19.3 (SD=2.4). Mean hemoglobin was found to be 13.2g/dl (SD=1.8). The average Harvard physical fitness score was found to be 40.7(SD=16.9). Pearson's correlations between SF-36 Physical Functioning and hemoglobin, BMI, and the Harvard Step-Test fitness score were 0.1, 0.1, and -0.1 respectively. There was no evidence that self-rating of OVC health outcomes differed by living arrangement. Using paired t-tests for continuous variables and chi-square tests for categorical variables, no significant p- values were obtained at the 95% level. Using a threshold of vision 20/20 for normal vision, 91.0% of community OVC and 78.8% of OVC in institutions had normal vision (p=0.07).

Conclusion: Although this study did not detect significant differences in self-reported measures of health among OVC in different living arrangements, physical examination revealed a slightly high incidence of poor vision among those living in institutions. In this sample, the correlations between SF-36 physical functioning sub-score and 3 physical health outcomes of BMI, hemoglobin, and the Harvard Step-test fitness score were weak.

The prevalence of hyperlipidemia, along with other non-communicable diseases, is on the rise in low- and middle-income countries. Given the resource-limited setting, a myriad of diagnostic challenges exist with traditional laboratory-based lipid tests, including mobility, timeliness, and laboratory infrastructure. Novel technology in the form of "point of care" devices seeks to overcome such barriers by providing immediate results without dependency on significant laboratory infrastructure. CardioChek PA (Polymer Technology Systems, Inc., Indianapolis, United States) is a point of care lipid measuring device and is readily available in Kenya. However, it has not been validated in this setting. In this study, I assess the accuracy of CardioChek PA with respect to standard laboratory-based testing, which is currently the gold standard.

In Webuye, Kenya, two blood samples were collected from 246 subjects to simultaneously measure the lipid levels via both CardioChek PA and the gold standard. All subjects were adults, and geographic stratified sampling methods were applied. Statistical analysis of the novel device's accuracy was based on percent bias, which is the standardized approach established by the National Cholesterol Education Program (NCEP) of the National Institute of Health (NIH). The NCEP suggests that percent bias be ≤±3% for low-density lipoprotein (LDL) cholesterol, ≤±5% for high-density lipoprotein (HDL) cholesterol, ≤±5% for total cholesterol (TC), and ≤±4% for triglycerides (TG). Misclassification rates and absolute percent bias were also analyzed.

This study found the CardioChek PA analyzer to be substantially inaccurate for LDL cholesterol (-25.9% bias), HDL cholesterol (-8.2% bias), and TC (-15.9% bias). For TG, the CardioChek PA performed well with a percent bias of 0.03%. However, the TG absolute percent bias (27.7%) and proportion of patients outside of the NCEP range (85%) reflected substantial inaccuracy of measurements. Moreover, those patients at higher risk of complications from hyperlipidemia were most likely to be misclassified into a lower risk category. Thus, we conclude that CardioChek PA is inaccurate and not suitable for our clinical setting. Furthermore, the findings highlight the need to validate new diagnostic tools in the appropriate setting prior to scale up regardless of its potential for novel utility.

Objective: Few studies have examined the disproportionate use of restraints for Black adults receiving emergency psychiatric care. This study sought to determine whether the odds of physical and chemical restraint use were higher for Black patients undergoing emergency psychiatric care compared with their white counterparts.

Methods: This single-center retrospective cohort study examined 12,977 unique encounters of adults receiving an emergency psychiatric evaluation between January 1, 2014, and September 18, 2020, at a large academic medical center in Durham, North Carolina. Self-reported race categories were extracted from the electronic medical record. Primary outcomes were the presence of a behavioral physical restraint order or chemical restraint administration during the emergency department encounter. Covariates included age, sex, ethnicity, height, time of arrival, positive urine drug screen results, peak blood-alcohol concentration, and diagnosis of a bipolar or psychotic disorder.

Results: A total of 961 (7.4%) encounters involved physical restraint, and 2,047 (15.8%) involved chemical restraint. Models with and without a race covariate were compared by using quasi-likelihood information criterion (QIC) scores; in each instance, the model with race performed better than the model without. Black patients were more likely to be physically (adjusted odds ratio [AOR]=1.35; 95% confidence interval [CI]=1.07–1.72) and chemically (AOR=1.33; 95% CI=1.15–1.55) restrained than white patients.

Conclusions: After adjusting for measured confounders, Black patients undergoing psychiatric evaluation were at higher odds of experiencing physical or chemical restraint compared with white patients, which is consistent with the growing body of evidence revealing racial inequities in psychiatric care.

Background: Acutely painful conditions, responsible for a large proportion of Emergency Department patients around the world, are inadequately assessed and poorly treated. Routine use of scales to quantify pain is recommended to improve analgesic practice. Currently, no such scale has been validated for use in Kiswahili-speaking patients in Tanzania. The objective of this study was to develop and assess a culturally relevant pain intensity scale for use in injury patients at the Kilimanjaro Christian Medical Center in Moshi, Tanzania. Methods: This was a two-part study, with the initial phase using focus groups to develop a pain scale. The second phase used a convenience sample of injury patients to assess the scale for validity and reliability. Analysis of variance, intra-class correlation coefficients, and Bland-Altman Analysis were used to assess validity and reliability. We used focus groups and surveys to develop a pain scale, which was subsequently tested in injury patients. Results: A 100-point numeric pain scale was developed and tested among 98 injury patients. The intra-class correlation coefficient of scores was 0.97 (95% CI 0.96 - 0.98) and Bland-Altman analysis found that 95% of the differences were between -23.5 and +20.7. Conclusions: Our results suggest that a 100-point numeric rating scale is valid and reliable for use Tanzanian injury patients.

Background:

Traumatic Brain Injury (TBI) is a leading cause of death and disability. TBI patients in low and middle- income countries (LMIC) have twice the odds of death than in high-income countries. There is limited data describing the epidemiology and mortality predictors for TBI in LMIC.

Objective:

Determine epidemiology and predictors of mortality in TBI patients at Kigali University Teaching Hospital Accident and Emergency Department (KUTH A&E).

Methods:

Consecutive, injured KUTH A&E patients were prospectively screened for inclusion by reported head trauma, alteration in consciousness, headache, or visible head trauma. Exclusion criteria were <10 years old, presenting >48 hours after injury, or repeat visits. Data were assessed for association with death using logistic regression. Significant variables were included in an adjusted multivariable logistic regression model then refined via backwards elimination until all variables were significant at P <0.05.

Results:

684 patients enrolled between October 7, 2013 and April 6, 2014. 12 (2%) were excluded due to incomplete data. 81% were male with mean age of 31.5 years (range 10 - 89). Most patients (75%) had mild TBI (Glasgow Coma Score (GCS) 14-15), while 15% had moderate (GCS 9-13), and 10% had severe TBI (GCS 3-8). Multivariable logistic regression and refinement by backwards elimination determined that GCS <14, hypoxia, tachycardia and age >50 years predicted mortality.

Conclusion:

GCS <14, hypoxia, tachycardia and age >50 years were associated with mortality among TBI patients at KUTH A&E. These findings can guide clinicians in prioritizing care for patients at highest risk of mortality.

Background: Chronic kidney disease (CKD) is increasingly prevalent worldwide. Several low and middle income countries, including Nicaragua, are particularly affected by CKD of unknown etiology (CKDu). CKDu disproportionately affects young people who lack traditional risk factors for CKD, and it may be due to heat stress, environmental exposures, nephrotoxic medications, or genetic conditions. The purpose of this study is to define the prevalence of CKD, CKD diagnosis awareness in those affected, and determine risk factors for CKD from traditional risk factors and CKDu in Nicaragua. Methods: Surveys and testing of urine and serum for CKD markers were performed in participants 15-59 years old in households of the León municipality in northwest Nicaragua. Surveys included data on demographics, health behaviors, occupation, and medical history. Those with CKD were subdivided into CKD with traditional risk factors and suspected CKDu. Statistical analysis includes proportions, non-parametric comparison tests, and multinomial logistic regression models. Results: CKD prevalence in 1795 study participants is 8.6%, and awareness of CKD among those affected was low (22%). Of those with CKD, 30% were suspected to have CKDu, which was associated with male sex, decreased socioeconomic status, water source of river or well, agricultural occupation, lower BMI, and smoking. Use of nephrotoxic medications and family history of CKD were associated with CKD from traditional risk factors. Conclusions: CKD from both traditional risk factors and CKDu is a significant burden in this region. Our study supports some previous hypotheses of CKDu etiology and emphasizes the importance of CKD screening.

Introduction: Traditional medicines are one of the most important means of achieving total health care coverage globally, and their importance in Tanzania extends beyond the impoverished rural areas. Their use remains high even in urban settings among the educated middle and upper classes. They are a critical component healthcare in Tanzania, but they also can have harmful side effects. Therefore we sought to understand the decision-making and reasoning processes by building an explanatory model for the use of traditional medicines in Tanzania.

Methods: We conducted a mixed-methods study between December 2013 and June 2014 in the Kilimanjaro Region of Tanzania. Using purposive sampling methods, we conducted focus group discussions (FGDs) and in-depth interviews of key informants, and the qualitative data were analyzed using an inductive Framework Method. A structured survey was created, piloted, and then administered it to a random sample of adults. We reported upon the reliability and validity of the structured survey, and we used triangulation from multiple sources to synthesize the qualitative and quantitative data.

Results: A total of five FGDs composed of 59 participants and 27 in-depth interviews were conducted in total. 16 of the in-depth interviews were with self-described traditional practitioners or herbal vendors. We identified five major thematic categories that relate to the decision to use traditional medicines in Kilimanjaro: healthcare delivery, disease understanding, credibility of the traditional practices, health status, and strong cultural beliefs.

A total of 473 participants (24.1% male) completed the structured survey. The most common reasons for taking traditional medicines were that they are more affordable (14%, 12.0-16.0), failure of hospital medicines (13%, 11.1-15.0), they work better (12%, 10.7-14.4), they are easier

to obtain (11%, 9.48-13.1), they are found naturally or free (8%, 6.56-9.68), hospital medicines have too many chemical (8%, 6.33-9.40), and they have fewer side effects (8%, 6.25-9.30). The most common uses of traditional medicines were for symptomatic conditions (42%), chronic diseases (14%), reproductive problems (11%), and malaria and febrile illnesses (10%). Participants currently taking hospital medicines for chronic conditions were nearly twice as likely to report traditional medicines usage in the past year (RR 1.97, p=0.05).

Conclusions: We built broad explanatory model for the use of traditional medicines in Kilimanjaro. The use of traditional medicines is not limited to rural or low socioeconomic populations and concurrent use of traditional medicines and biomedicine is high with frequent ethnomedical doctor shopping. Our model provides a working framework for understanding the complex interactions between biomedicine and traditional medicine. Future disease management and treatment programs will benefit from this understanding, and it can lead to synergistic policies with more effective implementation.

Importance: Quality improvement initiatives have been developed to improve clinical

outcomes in patients with heart failure (HF), but data from randomized trials of these

initiatives have not previously been synthesized.

Objective: To estimate the direction and magnitude of effect and quality of evidence for

hospital-based HF quality improvement interventions on process of care measures and

clinical outcomes among patients with acute HF.

Evidence Review: We performed a structured search to identify relevant randomized

trials through February 2017. Studies were independently reviewed in duplicate for key

characteristics, outcomes were summarized, and a qualitative synthesis was performed

due to substantial heterogeneity.

Findings: From 3,615 records, 14 randomized controlled trials were identified for

inclusion with multi-faceted interventions. The mean in-hospital mortality rate reported in

three trials (n = 75,164 participants) ranged from 3.4% to 5.6% in the intervention

compared to 3.4% to 15.4% in the comparator. There was a trend towards higher inhospital

use of angiotensin converting enzyme inhibitors (ACE-I; 57.9% versus 40.0%)

and beta-blockers (BB; 46.7% versus 10.2%) in the intervention than the comparator in

one trial (n = 429 participants). Five trials (n = 78,727 participants) demonstrated no

effect of the quality improvement intervention on use of ACE-I or angiotensin receptor

blocker (ARB) at discharge; whereas, one trial (n = 17,544 participants) demonstrated

an increase in ACE-I or ARB use at discharge (86.1% to 92.4%, absolute difference

5.9%; 95% CI 1.0, 10.7; P = 0.02). Three trials (n = 89,660 participants) reported no

effect on use of BB at discharge, and one trial (n = 71,829 participants) reported no

effect on use of aldosterone antagonist at discharge. Two trials (n = 419 participants)

demonstrated a trend towards lower hospital readmission up to 90 days after discharge.

There was no consistent effect of the quality improvement intervention on 30-day allcause

mortality, hospital length of stay, and patient-level health-related quality of life.

Conclusions and Relevance: Randomized trials of hospital-based HF quality

improvement interventions do not show a consistent effect on most process of care

measures and clinical outcomes. The overall quality of evidence for these outcomes is

very low to moderate, suggesting that future research will likely influence these

estimates.

Motorcycle crash related injuries and deaths are increasing rapidly in many African nations. Utilizing conspicuity measures, such as wearing reflective, fluorescent safety vests, are effective as crash prevention strategies. Furthermore, use of some conspicuity measures is mandated by law among motorcycle-taxi drivers in Tanzania. Nonetheless, uptake remains low. Locally appropriate strategies to improve crash preventative behaviors are needed.

To explore whether use of conspicuity measures could be improved through eliminating cost-barriers, we tested a distribution strategy involving the provision of free motorcycle safety vests among a population of motorcycle-taxi drivers in Moshi, Tanzania. We conducted a cluster randomized controlled trial among 180 motorcycle-taxi drivers in which half of the participants (90) were randomized to the intervention arm and received a free reflective vest. The other half of the participants (90) were randomized to the control arm and did not receive free vests. Whether motorcycle taxi drivers used the reflective vest was then unobtrusively observed on city streets over a period of three months.

Mixed-effects logistic regression was used to estimate differential uptake of the vests between trial arms. At baseline, 3.3% of individuals in both arms used a reflective vest. In three months of follow-up, 79 drivers in the intervention arm and 82 drivers in the control arm were able to be observed. In the intervention arm the average proportion of observations during which drivers were observed to be using a reflective vest was 9.5%, compared to 2.0% in the control arm (odds ratio: 5.5, 95% confidence interval: 1.1-26.9, p-value: 0.04). Distribution of free reflective vests did lead to an increase in vest usage, however, the increase was minimal. Removing economic barriers alone appears insufficient to adequately improve adherence to conspicuity measures.

There is little information regarding the knowledge, attitudes and practices of obstetric care providers in Rwanda, who are a crucial component for providing quality Safe Motherhood care. Despite investments in the structural capacity needed to deliver these services, little has been directed towards understanding the current competency of skilled providers on the front lines of maternal mortality and morbidity prevention. This study surveyed 87% of all obstetric care providers in the Bugesera District of Rwanda to determine their demographic characteristics, competency in Safe Motherhood knowledge, obstetric practices, and attitudes towards patients and training approaches. The study identified the majority of providers to be A2 level nurses (82%) who have received one year of health education in secondary school. In addition, the majority of providers expressed that both their knowledge (60.6%) and skills confidence (72.2%) across fundamental topics of Safe Motherhood care need improvement. There was a low level of demonstrated knowledge in Safe Motherhood services with a mean of 46.4% of 50 questions answered correctly. Performance of knowledge in normal labor (39.3% correct) and obstetric complications (37.1% correct) were the weakest areas identified. A high percentage of providers (60.8%) engage in the potentially harmful practice of fundal pressure during vaginal delivery, while only 15.9% of providers practice steps of the active management of the third stage of labor in 100% of their deliveries. Providers view additional education and training in emergency obstetric care (EMOC) to be very useful, with 89.3% reporting an enthusiastic willingness for participation in a two-day workshop even if it was their day off. Improving knowledge, skills and practices of obstetric providers is an essential step in improving the quality of emergency obstetric care.

Background: Brick kiln workers in Nepal are a neglected population who are exposed to high concentrations of respirable silica. We aimed to characterize the prevalence of respiratory personal protective equipment (PPE) use, understand knowledge and attitudes towards kiln dust and respiratory PPE, and identify factors associated with current respiratory PPE use among brick kiln workers in Nepal. Methods: We conducted a cross-sectional study in Bhaktapur, Nepal. We used simple random selection to identify 10 out of 64 total kilns and stratified random sampling to enroll workers aged ≥14 years and household members aged ≥9 years within selected kilns. Field workers surveyed participants using structured questionnaires. Our primary outcome was to characterize prevalence of current respiratory PPE use, and secondary outcomes were summaries of knowledge, attitudes, and practice of PPE use. Results: We surveyed 83 workers (mean age 30.8 years, 77.1% male). Of these, 28.9% reported current respiratory PPE use at work. 3.6% of workers heard of silicosis prior to the survey and 24.1% correctly identified the best respiratory PPE for reducing dust exposure. Respiratory PPE users had higher income (non-brick kiln season mean monthly household income USD 206 vs. 145) and education levels (25% vs. 5.1% completed more than primary school) compared to non-users. Conclusions: Prevalence of respiratory PPE use was low. Workers had poor knowledge of kiln dust health effects and proper respiratory PPE. We highlight important barriers to PPE use, particularly knowledge gaps, which can guide future investigations to reduce silicosis burden among brick kiln workers.

Background: Thalassemia is a devastating inherited hematological disorder, and as a result of population migration, has become a global public health problem. Thailand has one of the highest burdens of thalassemia in the world and has developed a successful prevention and control program, but nearly 4 million migrants living in Thailand are excluded. Strategies for thalassemia screening in migrants are needed. This study aims to characterize migrants' awareness and knowledge of and attitudes toward thalassemia screening. Methods: 300 adult Myanmar or Cambodian migrant workers and 200 adult Thai citizens residing in the industrial province of Chonburi, Thailand were enrolled and given a demographic and KAP (Knowledge, Attitudes, and Practices) survey on thalassemia. Descriptive statistics, tabulations, Wilcoxon Rank Sum Tests, Kruskal-Wallis Test, and Chi-Square analysis were used to compare socio-demographic variables and levels of thalassemia awareness between migrant and Thai subjects. Results: Myanmar and Cambodian subjects had very low awareness of thalassemia, in contrast with Thai subjects (4.1% vs 79.6%, respectively). Migrants also had lower knowledge of thalassemia, but showed strong interest in thalassemia screening. Gender and education level predicted thalassemia awareness in Thai subjects, but length of residence in Thailand was the only demographic variable associated with awareness in migrants. Conclusions: This study revealed a tremendous awareness gap between Thai and migrant populations surrounding thalassemia, suggesting that public education is a crucial starting point for a thalassemia prevention and control program in migrants. A number of structural and cultural barriers identified in this study will also need to be addressed.

Background: People living with HIV (PLWH) are at increased risk for ischemic heart disease (IHD) and myocardial infarction (MI). Our objectives in this study were the following: identify the prevalence of prior MI and myocardial ischemia among PLWH, compare with HIV-uninfected participants, identify correlates of prior MI among PLWH; examine PLWH knowledge, attitudes, and practices (KAP) regarding IHD, identify predictors of improved knowledge, and explore patient and provider perspectives on barriers to MI care. Methods: Adults presenting for routine HIV-care were recruited. Trained research assistants collected basic sociodemographic information and medical history and administered a standardized knowledge, attitudes, and practices survey regarding IHD. An IHD knowledge score between 0 and 10 was calculated for each participant based on the number of correct answers on the KAP knowledge questions. Associations between participant characteristics and IHD knowledge scores were assessed via Welch’s t-test. Age- and sex- matched participants without HIV were selected as controls from an outpatient department in the same district. Both PLWH and control participants underwent 12-lead resting ECG testing. ECG criteria for prior MI was defined as pathologic Q waves in ≥2 contiguous lead and myocardial ischemia as ST segment depression or T wave inversion in ≥2 contiguous leads. Each ECG was reviewed by two independent physician adjudicators, and Pearson’s chi-squared test was used to compare the prevalence of ischemic ECG findings among those with and without HIV. Multivariate logistic regression was also performed to identify patient characteristics correlating with prior MI in PLWH on ECG. Finally, PLWH with ECG findings of prior MI and physicians caring for PLWH were recruited via purposive sampling for in-depth interviews regarding barriers to MI care in PLWH. Inductive thematic analysis was conducted to identify emergent themes and all transcripts were independently coded in NVivo 12. Results: Of 500 enrolled PLWH, the mean (sd) age was 45.3 (11.4) years and 139 were (27.8%) males. The study found an average knowledge score of 5.6, with higher IHD knowledge scores being associated with post-primary education (mean = 6.27 vs 5.35, p = 0.001) and with >10% five-year risk of cardiovascular event (mean = 5.97 vs 5.41, p = 0.045). Control participants without HIV were recruited for 497 participants with HIV. Prior MI (11.1% vs 2.4%, OR 4.97, 95% CI: 2.71-9.89, p<0.001), and myocardial ischemia (18.7% vs 12.1% OR 1.67, 95% CI: 1.18-2.39, p=0.004) were significantly more common among participants with HIV than those without HIV. On multivariate analysis, prior MI among participants with HIV was associated with male sex (OR 2.05, 95% CI: 1.06-3.89, p=0.030) and self-reported family history of cardiovascular disease (OR 2.05, 95% CI: 1.05-3.88, p=0.031). The 24 in-depth interviews of providers and patients revealed barriers related to perceptions and understanding of MI among patients and providers, delays in MI diagnosis and initiation of treatment, and challenges in the provision of long-term MI care. Conclusions: Tanzanians with HIV have a significantly higher burden of IHD than those without HIV, but significant barriers exist to high quality cardiovascular care in this population. Further study is required to characterize cardiovascular disease burden and improve care for PLWH.

Background: In North America and Europe, SLE is more common and severe in people of African extraction than in Caucasians; however, the epidemiology of SLE in Africa is largely undetermined. Historically, the incidence of SLE in Africa was presumed to be low, but recent studies challenge this theory. In general, children present with higher disease activity, require more therapy, and accrue more organ damage than adult-onset patients. Although African children with SLE may be at high risk for poor outcomes, little research has investigated this population. We have initiated the first registry of this high risk pediatric SLE (pSLE) population in South Africa (SA). Here, we report the initial findings of the South African pSLE patients (PULSE cohort).

Methods: We conducted a cross sectional analysis (retrospective and prospective chart review) of pediatric and adult rheumatology and nephrology patients seen at 2 centers in Cape Town, South Africa from 1988-2014 meeting American College of Rheumatology criteria for pSLE. Patient age, gender, race, presenting features, clinical and serologic disease markers, and treatment were recorded for the PULSE cohort and compared to an established North American pSLE cohort.

Results: Initial review of patients yielded 72 patients (age 11.5; 83% female). The racial distribution was 68% colored, 26% black, 5% white, and 3% Asian/Indian. Most patients presented with severe lupus nephritis (LN) (renal biopsy performed in 58%)). Of patients with LN, 93% presented with ISN class III or higher. Within the SA cohort, 13% went on to develop ESRD, of which 9% required transplant, strikingly higher than NA peers. There were treatment differences between cohorts: patients in the North American cohort had increased use of MMF and biologic therapies. The SA cohort had severe disease at diagnosis (mean SLEDAI 20.6), compared to the NA pSLE cohort (SLEDAI 4.8). Also, the PULSE cohort had end organ damage with 63% of the cohort having a SLICC score >0 (mean SLICC 1.9), compared to only 23% in a previously reported US cohort of 221 pSLE patients.

Conclusions: The PULSE cohort is the largest registry of pSLE patients in Africa to date. These children present with high disease activity and progress to end organ damage at higher rates than pSLE cohorts in developed nations. Further research is required to determine the risk factors for poor outcomes in this high risk population.

Background: Post-cesarean section peritonitis is the leading cause of maternal morbidity and mortality at the main referral hospital in Rwanda. Published data on the management of post-cesarean section peritonitis is limited. This study examined predictors of maternal morbidity and mortality for post-cesarean peritonitis.

Methods: We performed a prospective observational cohort study at the University Teaching Hospital Kigali (CHUK) from January 1 until December 31 2015, followed by a retrospective chart review of all subjects with post-cesarean section peritonitis admitted to CHUK from January 1 until December 31, 2014. All patients admitted with the diagnosis of post-cesarean section peritonitis undergoing exploratory laparotomy at CHUK were enrolled. Patients were followed to either discharge or death. Study variables included baseline demographic/clinical characteristics, admission physical exam, intraoperative findings, and management. Data were analyzed using STATA version 14.

Results: Of the 167 patients enrolled, 81 survived without requiring hysterectomy (49%), 49 survived requiring hysterectomy (29%), and 36 died (22%). In the multivariate analysis, severe sepsis was the most significant predictor of mortality (RR=4.0 [2.2-7.7]) and uterine necrosis was the most significant predictor of hysterectomy (RR=6.3 [1.6-25.2]). There were high rates of antimicrobial resistance (AMR) among the bacterial isolates cultured from intra-abdominal pus, with 52% of bacteria resistant to third-generation cephalosporins.

Conclusions: Post-cesarean section peritonitis carries a high mortality rate in Rwanda. It is also associated with a high rate of hysterectomy. Understanding the disease process and identifying factors associated with outcomes can help guide management during admission.