Browsing by Subject "Outcomes"

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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

Methods

Results

Conclusions

Background: Acute lower respiratory infection (ALRI) is the leading infectious cause of death among children worldwide, and respiratory syncytial virus is the most common cause of ALRI. The majority of deaths occur in low- and middle-income countries, but there is a dearth of data on risk factors for poor outcomes in these settings. We endeavored to identify clinical and microbiome-related factors associated with poor outcomes among children hospitalized with RSV-ALRI in Gaborone, Botswana. Methods: Children 1-23 months of age presenting for care at Princess Marina Hospital who met the World Health Organization (WHO) definition of clinical pneumonia were enrolled in this prospective study and followed until hospital discharge or death. Nasopharyngeal swabs were collected for respiratory viral testing and microbiome analysis. Results: Young age (<6 months), household use of wood as a cooking fuel, moderate or severe malnutrition, and oxygen saturation <90% on room air were independent predictors of clinical nonresponse at 48 hours. Among HIV-uninfected infants 6 months of age or younger, HIV exposure was associated with a higher risk of in-hospital mortality. Nasopharyngeal microbiome composition and diversity were not associated with clinical nonresponse. Conclusions: We identified several risk factors for poor outcomes from RSV-ALRI among children in Botswana. These data could inform future use of RSV vaccines and therapeutics in these populations.

Background: There is a rising burden of myocardial infarction (MI) within sub-Saharan Africa. Prospective studies of detailed MI outcomes in the region are lacking.

Methods:Adult patients with confirmed MI from a prospective surveillance study in northern Tanzania were enrolled in a longitudinal cohort study after baseline health history, medication use, barriers to care, and sociodemographics were obtained. Thirty days following hospital presentation, symptom status, rehospitalizations, medication use, and mortality were assessed via telephone or in-person interviews using a standardized follow-up questionnaire. Multivariate logistic regression was performed to identify baseline predictors of thirty-day survival.

Results:Thirty-day follow-up was achieved for 150 (98.7%) of 152 enrolled participants. Of these, 85 (56·7%) survived to thirty-day follow-up. Of the surviving participants, 71 (83·5%) reported persistent anginal symptoms, four (4·7%) reported taking aspirin regularly, seven (8·2%) were able to identify MI as the reason for their hospitalization, and 17 (20·0%) had unscheduled rehospitalizations. Baseline predictors of thirty-day survival included self-reported history of diabetes (OR 0·32, 95% CI 0·10-0·89, p = 0·04), self-reported history of hypertension (OR 0·34, 95% CI 0·15-0·74, p = 0·01) and antiplatelet use at initial presentation (OR 0·19, 95% CI 0·04-0·65, p = 0·02).

Conclusions:In northern Tanzania, thirty-day outcomes following acute MI are poor, and mortality is associated with comorbidities and medication usage. Further investigation is needed to develop interventions to improve care and outcomes of MI in Tanzania.

Background: Each year, 2 million older Americans complete three to four week courses of post-acute care in nursing homes and return home; however, scant research describes services to protect older adults during their transitions from nursing homes to home. In hospital-based studies, transitional care interventions were associated with improved health outcomes for older adults, but these interventions added new staff positions, which are likely cost-prohibitive in nursing homes. Further, no prior study explored transitional care provided for vulnerable, post-acute care patients in nursing homes. Thus, this dissertation was designed to develop new understandings about transitional care provided by existing staff members in nursing homes. The study has two specific aims: (a) describe transitional care and outcomes for older adults who obtain post-acute care in nursing homes from the day of admission through discharge; (b) explore the influence of interactions, among selected older adult patients and their group of nursing home caregivers, on their ability to accomplish transitional care processes.

Method: Using data from a literature review and theoretical models, including Donabedian's Model of Healthcare Quality and Anderson's Local Interaction Model, a conceptual model of transitional care for post-acute care patients in nursing homes was constructed. The conceptual model was then used to guide exploration of the research aims with a longitudinal, multiple case study of transitional care in a nursing home. The unit of analysis was the patient care-team, defined as individual post-acute care patients, family caregivers, and 6 to 8 professional staff in each team (e.g., rehabilitation therapists, physicians, nurses and social workers). Three patient care-team members were purposively sampled for study. Moreover, longitudinal data were collected using repeated interviews and observations with patients, family caregivers, and staff; document and daily chart reviews; and surveys of patient preparedness for discharge. Manifest content analysis and thematic analysis (qualitative methods) were used to conduct within- and across-case analyses of trajectories of transitional care and to identify strengths, gaps and inconsistencies in care.

Results: Findings related to the first research aim include a description of transitional care in the study nursing home. Serious gaps and inconsistencies in transitional care exposed older, post-acute care patients to risks for complications in their transitions from the study nursing home to home: (a) systemic supports were not available to support nursing home staff who provided transitional care; further, nursing home staff and leadership were unaware that they provided transitional care; (b) care processes were not in place to prepare older adults and their caregivers to continue care at home; (c) care-team interactions often excluded family members; and (d) post-acute care patients left the nursing home without resources needed to support safe transitions in care, including transitional care plans, education to appropriately respond to acute changes in health, written materials to guide care at home, referrals for medical follow-up after discharge, and transfers of clinical information to primary care physicians.

Findings related to the second research aim include a description of local interaction strategies and the effectiveness of transitional care processes. When professional staff more consistently used local interaction strategies, specified in the model, care-team members exhibited greater capacity for connections, information exchange, and cognitive diversity. Further, when care-team interactions were of high quality and sufficient frequency, there were multiple indications of more effective transitional care, such as patient engagement in care, inclusion of patient priorities in care plans, and problem solving which included family members and diverse members of the patient care-team. Thus, local interaction strategies were essential staff behaviors needed to adapt care processes to the specific transitional care needs of individual patients.

Because transitional care is a grossly under-developed care process in nursing homes, these findings will likely have immediate implications for practice and research. Findings will provide nursing home administrators and staff with resources to develop and evaluate care in nursing homes; further, the findings will help to create targets for protocol and care process development to strengthen existing practice and address deficiencies. Findings will provide researchers with resources for studying transitional care in diverse samples of nursing homes, which should facilitate development of testable hypotheses for needed intervention studies. In addition, the local interaction strategies findings in the study may generalize to other settings of care, where interdependent staff work is required to establish connections, information networks, and to coordinate care among multiple staff members.