Electronic Integrated Management of Childhood Illness (eIMCI): a randomized controlled trial to evaluate an electronic clinical decision-making support system for management of sick children in primary health care facilities in South Africa.

BACKGROUND: Electronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa. METHODS: We conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert. RESULTS: Self-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants. CONCLUSIONS: Implementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349) CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov ID: BFC157/19, August 2019.

Outlier or handover: outcomes for General Medicine inpatients.

Objective Patients admitted from the emergency department may be co-located on the treating team's 'home ward'. If no bed is available, patients may be sent to another ward, where they may remain under the admitting team as an 'outlier'. Conversely, care may be handed over to the team on whose home ward they are located. We conducted a retrospective analysis to understand the impact of outlier status and handovers of care on outcomes for General Medicine inpatients. Methods General Medicine admissions at the Royal Adelaide Hospital between September 2020 and November 2021 were analysed. We examined the rate of hospital-acquired complications, inpatient mortality rate, mortality within 48 h of admission, Relative Stay Index, time of discharge from hospital and rate of adverse events within 28 days of discharge. Results A total of 3109 admissions were analysed. Handovers within 24 h of admission were associated with a longer length of stay. There was a trend towards higher rates of adverse events within 28 days of discharge with handovers of care. Outlier status did not affect any outcome measures. Conclusions Handovers within the first 24 h of admission are associated with longer than expected length of stay.

High-'n'-dry? A comparison of cannabis and alcohol use in drivers presenting to hospital after a vehicular collision.

DESIGN: This was a prospective observational study. BACKGROUND AND AIMS: The characteristics of cannabis-involved motor vehicle collisions are poorly understood. This study of injured drivers identifies demographic and collision characteristics associated with high tetrahydrocannabinol (THC) concentrations. SETTING: The study was conducted in 15 Canadian trauma centres between January 2018 and December 2021. CASES: The cases (n = 6956) comprised injured drivers who required blood testing as part of routine trauma care. MEASUREMENTS: We quantified whole blood THC and blood alcohol concentration (BAC) and recorded driver sex, age and postal code, time of crash, crash type and injury severity. We defined three driver groups: high THC (THC ≥ 5 ng/ml and BAC = 0), high alcohol (BAC ≥ 0.08% and THC = 0) and THC/BAC-negative (THC = 0 = BAC). We used logistic regression techniques to identify factors associated with group membership. FINDINGS: Most injured drivers (70.2%) were THC/BAC-negative; 1274 (18.3%) had THC > 0, including 186 (2.7%) in the high THC group; 1161 (16.7%) had BAC > 0, including 606 (8.7%) in the high BAC group. Males and drivers aged less than 45 years had higher adjusted odds of being in the high THC group (versus the THC/BAC-negative group). Importantly, 4.6% of drivers aged less than 19 years had THC ≥ 5 ng/ml, and drivers aged less than 19 years had higher unadjusted odds of being in the high THC group than drivers aged 45-54 years. Males, drivers aged 19-44 years, rural drivers, seriously injured drivers and drivers injured in single-vehicle, night-time or weekend collisions had higher adjusted odds ratios (aORs) for being in the high alcohol group (versus THC/BAC-negative). Drivers aged less than 35 or more than 65 years and drivers involved in multi-vehicle, daytime or weekday collisions had higher adjusted odds for being in the high THC group (versus the high BAC group). CONCLUSIONS: In Canada, risk factors for cannabis-related motor vehicle collisions appear to differ from those for alcohol-related motor vehicle collisions. The collision factors associated with alcohol (single-vehicle, night-time, weekend, rural, serious injury) are not associated with cannabis-related collisions. Demographic factors (young drivers, male drivers) are associated with both alcohol and cannabis-related collisions, but are more strongly associated with cannabis-related collisions.

Characteristics and outcomes of patients with heart failure discharged from different speciality units in Australia: an observational study.

BACKGROUND: Previous studies have reported differing clinical outcomes among hospitalized heart failure (HF) patients admitted under cardiology and general medicine (GM) without consideration of patients' frailty. AIMS: To explore outcomes in patients admitted under the two specialities after taking into account their frailty and other characteristics. METHODS: This retrospective study included all HF patients ≥18 years admitted between 1 January 2013 and 31 December 2019 at two Australian tertiary hospitals. Frailty was determined by use of the Hospital Frailty Risk Score (HFRS) and patients with HFRS ≥ 5 were classified as frail. Propensity score matching (PSM) was used to match 11 variables between the two specialities. The primary outcomes included the days-alive-and-out-of-hospital (DAOH90) at 90 days of discharge, 30-day mortality and readmissions. RESULTS: Of 4913 HF patients, mean age 76.2 (14.1) years, 51% males, 2653 (54%) were admitted under cardiology compared to 2260 (46%) under GM. Patients admitted under GM were more likely to be older females, with a higher Charlson index and poor renal function than those admitted under cardiology. Overall, 23.8% patients were frail and frail patients were more likely to be admitted under GM than cardiology (33.6% vs. 15.3%, P < 0.001). PSM created 1532 well-matched patients in each group. After PSM, the DAOH90 was not significantly different among patients admitted in GM when compared to cardiology (coefficient -5.36, 95% confidence interval -11.73 to 1.01, P = 0.099). Other clinical outcomes were also similar between the two specialities. CONCLUSIONS: Clinical characteristics of HF patients differ between GM and cardiology; however, clinical outcomes were not significantly different after taking into account frailty and other variables.

Attitudes and perceptions about breastfeeding among female and male informal workers in India and South Africa.

BACKGROUND: Worldwide, over 740 million women make their living in the informal economy and therefore lack formal employment benefits, such as maternity leave, that can improve infant feeding practices. Returning to work is one of the biggest challenges women face to maintaining breastfeeding. This study aimed to explore attitudes and perceptions towards breastfeeding in the informal work environment among male and female informal workers. METHODS: The study used a qualitative research design. Purposive and snowball sampling was employed. Focus group discussions (FGDs) were conducted among men and women working in different types of informal jobs, in India and South Africa. Data was analysed using a thematic approach and the framework method. RESULTS: Between March and July 2017, 14 FGDs were conducted in South Africa and nine in India. Most women were knowledgeable about the benefits of breastfeeding and reported initiating breastfeeding. However, pressures of family responsibilities and household financial obligations frequently forced mothers to return to work soon after childbirth. Upon return to work many mothers changed their infant feeding practices, adding breastmilk substitutes like formula milk, buffalo milk, and non-nutritive fluids like Rooibos tea. Some mothers expressed breastmilk to feed the infant while working but many mothers raised concerns about expressed breastmilk becoming 'spoilt'. Breastfeeding in the workplace was challenging as the work environment was described as unsafe and unhygienic for breastfeeding. Mothers also described being unable to complete work tasks while caring for an infant. In contrast, the flexibility of informal work allowed some mothers to successfully balance competing priorities of childcare and work. Sociocultural challenges influenced breastfeeding practices. For example, men in both countries expressed mixed views about breastfeeding. Breastfeeding was perceived as beneficial for both mother and child, however it was culturally unacceptable for women to breastfeed in public. This affected working mothers' ability to breastfeed outside the home and contributed to a lack of respect for women who chose to breastfeed in the workplace. CONCLUSION: Mothers working in the informal sector face multiple challenges to maintaining breastfeeding. Interventions are required to support feeding and childcare if global nutrition and development goals are to be met.

Are we doing enough? Improved breastfeeding practices at 14 weeks but challenges of non-initiation and early cessation of breastfeeding remain: findings of two consecutive cross-sectional surveys in KwaZulu-Natal, South Africa.

BACKGROUND: KwaZulu-Natal (KZN) Initiative for breastfeeding support (KIBS) was a multipronged intervention to support the initiation and sustaining of breastfeeding, implemented between 2014 and 2017. We present results of two surveys conducted before and after KIBS implementation to assess changes in infant feeding practices in KZN over this time period. METHODS: Two cross-sectional surveys were conducted in primary health care clinics. Multistage stratified random sampling was used to select clinics and participants. Sample size was calculated to provide district estimates of 14-week exclusive breastfeeding (EBF) rates at baseline (KIBS1), and provincial estimates at endpoint (KIBS2). At KIBS1 the sample required was nine participating clinics in each of 11 districts (99 clinics) with 369 participants per district (N = 4059), and at KIBS2 was 30 clinics in KZN with 30 participants per clinic (N = 900). All caregivers aged ≥15 years attending the clinic with infants aged 13- < 16 weeks were eligible to participate. Data was collected using structured interviews on android devices. Multi-variable logistic regression was used to adjust odds ratios for differences between time points. RESULTS: At KIBS1 (May2014- March2015), 4172 interviews were conducted with carers, of whom 3659 (87.6%) were mothers. At KIBS2 (January-August 2017), 929 interviews were conducted which included 788 (84.8%) mothers. Among all carers the proportion exclusively breastfeeding was 44.6 and 50.5% (p = 0.1) at KIBS1 and KIBS2 respectively, but greater improvements in EBF were shown among mothers (49.9 vs 59.1: p = 0.02). There were reductions in mixed breastfeeding among all infants (23.2% vs 16.3%; p = 0.016). Although there was no change in the proportion of carers who reported not breastfeeding (31.9% vs 32.8%; p = 0.2), the duration of breastfeeding among mothers who had stopped breastfeeding was longer at KIBS2 compared to KIBS1 (p = 0.0015). Mothers who had returned to work or school were less likely to be breastfeeding (adjusted odds ratio [AOR] 3.76; 95% CI 3.1-4.6), as were HIV positive mothers (AOR 2.1; 95% CI 1.7-2.6). CONCLUSION: Despite improvements to exclusive breastfeeding, failure to initiate and sustain breastfeeding is a challenge to achieving optimal breastfeeding practices. Interventions are required to address these challenges and support breastfeeding particularly among working mothers and HIV positive mothers.

The Effect of Age upon the Interrelationship of BMI and Inpatient Health Outcomes.

OBJECTIVES: There is growing evidence that the relationship between body mass index (BMI - defined as weight in kilograms divided by height in metres squared) and patient outcomes is age-dependent; specifically, a raised BMI may have a protective effect in older adults. This has been demonstrated clearly in the community setting; less clear is the effect of age on this relationship in the inpatient setting. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: Retrospective analysis of 22,903 electronic records for patients discharged from two large public hospitals in South Australia between January 2015 and September 2018 inclusively. Records were retained if the patient's height and weight had been recorded during the admission, BMI was between 10-99 kg/m2 and it was the patient's first admission during that time. Patients were grouped by BMI (<18.5 kg/m2 ("underweight"), 18.5-24.9 kg/m2 ("normal weight"), 25-29.9 kg/m2 ("overweight"), >30 kg/m2 ("obese")) and age (18-59 years, 60-79 years, > 80 years); for each group we measured the relative stay index (RSI) (actual length of stay divided by predicted length of stay), death in hospital and composite adverse outcome after discharge (unplanned readmission within 30 days and/or death within 30 days). RESULTS: Underweight patients across all age groups generally experienced significantly poorer outcomes compared to those not underweight. In those aged 18-59 years there were no significant differences in outcomes between the normal weight, overweight and obese groups. In those aged 60-79 years overweight patients had a significantly reduced risk of RSI > 2 compared to those of normal weight (p=0.014), and both overweight and obese patients had a significantly reduced risk of adverse outcome after discharge when compared to those of normal weight (p=0.028 and p=0.009 respectively). In those aged 80 years or older, both overweight and obese patients had a significantly reduced risk of adverse outcome after discharge when compared to those of normal weight (p=0.028 and p=0.013 respectively), and obese patients had a significantly reduced risk of inpatient mortality and RSI >2 when compared to those of normal weight (p=0.027 and p=0.037 respectively). CONCLUSION: A BMI > 25 kg/m2 in older patients is associated with reduced risk of prolonged admission, inpatient mortality and adverse outcomes following discharge. This adds to growing evidence that age-specific BMI guidelines are required for adults because the healthiest BMI in the older hospital patient is seemingly not in the range 18.5-24.9 kg/m2.

A health systems strengthening intervention to improve quality of care for sick and small newborn infants: results from an evaluation in district hospitals in KwaZulu-Natal, South Africa.

BACKGROUND: Many newborn infants die from preventable causes in South Africa, often these deaths occur in district hospitals. A multipronged intervention aiming to improve quality of newborn care in district hospitals was implemented comprising training in clinical care for sick and small newborns, skills development for health managers, on-site mentoring, and hospital accreditation. We present the results of the project evaluation. METHODS: We conducted three sequential cross-sectional surveys in 39 participating district hospitals at baseline, midpoint and endpoint of the three-year intervention period. Data were collected by a trained midwife using a series of checklists including: availability of trained staff, drugs and equipment; newborn care practices; perinatal mortality audits; neonatal unit staff skills; quality of record keeping. A scoring system was developed for three domains: resources; care practices; resuscitation equipment, and a composite score that included all variables measured. Health worker (HW) knowledge was assessed at midpoint and endpoint. RESULTS: The average score for resources increased from 13.5 at baseline to 22.6 at endpoint (maximum score 34), for care practices from 17.7 to 22.6 (maximum score 29), and for resuscitation equipment from 10.8 to 16.1 (maximum 25). Average composite score improved significantly from 42.0 at baseline to 55.7 at midpoint to 60.7 at endpoint (maximum score 88) (p = 0.0012). Among 39 participating hospitals, 38 achieved higher scores at endpoint compared to baseline. Knowledge was higher among HWs trained during the project at midpoint and endpoint. Gaps that remained included poor infrastructure, lack of resuscitation equipment in some areas, poor postnatal care and lack of a dedicated doctor. CONCLUSIONS: This intervention achieved measurable improvements in many important elements contributing to newborn care. A scoring system was used to track progress, compare facilities' performance, and identify areas for improvement. Various methods were used to generate the quality of care score, including skills assessment and record reviews. However, measuring quality of clinical care and outcomes was challenging, and we were unable to determine whether the intervention improved clinical care and lead directly to improved outcomes for babies. In developing a future score for quality of care, a stronger focus should be placed on assessing clinical care and outcomes.

Improved rates of exclusive breastfeeding at 14 weeks of age in KwaZulu Natal, South Africa: what are the challenges now?

BACKGROUND: Increasing the rate of exclusive breastfeeding (EBF) to 50% in the first six months of life is one of six major global targets set by the United Nations Decade of Nutrition, and is essential to achieve the sustainable development goals to eradicate hunger and end malnutrition by 2030. METHODS: A survey using multistage random sampling design included 99 primary health care (PHC) clinics in all 11 districts in KwaZulu-Natal (KZN). All mothers and caregivers of infants 14 weeks of age attending the clinics in the study period were requested to participate in a structured interview to explore feeding practices since birth. As non-maternal caregivers may not have detailed knowledge of feeding practices, they provided limited information about current feeding practices. Respondents who consistently reported giving no other food or fluids except breastmilk since birth were classified as practising exclusive breastfeeding (EBF), and those who were currently breastfeeding but had given other food or fluids since birth were categorised as practising mixed breastfeeding (MBF). RESULTS: A total of 4172 interviews were conducted with mothers and caregivers of 14 week old infants. Among mothers 49.8% were EBF, 23.1% were MBF and 27.0% were not breastfeeding. Among non-maternal caregivers 11.8% reported EBF, 23.4% MBF and 62.3% were not giving breastmilk. Higher education (OR 0.6, 95% CI 0.4-0.8) and being in the highest socio-economic tertile (OR 0.7, 95% CI 0.6-0.9) were risk factors for not practising EBF, while returning to work (OR 0.3, 95% CI 0.2-0.3) or school (OR 0.2 95% CI, 0.1-0.3) was associated with less EBF. HIV-positive mothers were more likely to have never started breastfeeding (OR 3.6, 95% CI 2.7-4.8). However, they were similar in having stopped breastfeeding by 14 weeks (OR 1.1, 95% CI 0.9-1.4) compared to HIV-negative mothers, and, they had similar rates of EBF at 14 weeks of age (OR 1.0, 95% CI 0.9-1.3). CONCLUSIONS: Estimates of breastfeeding practices at 14 weeks in KZN are higher than previously shown. However, particular challenges that should be addressed if international targets for EBF are to be achieved include improving breastfeeding practices of HIV positive mothers and supporting all mothers, particularly working or schooling mothers to continue giving breastmilk while they are away from their children.

Comparison of specialist and generalist care.

Objective The choice of whether to admit under a specialist or a generalist unit is often made with neither clear rationale nor understanding of its consequences. The present study compared the characteristics and outcomes of patients admitted with community-acquired pneumonia to either a general medicine or respiratory unit. Methods This study was a retrospective cross-sectional study using data from public hospitals in Adelaide, South Australia. Over 5 years there were 9775 overnight, unplanned appropriate adult admissions. Patient length of hospital stay, in-patient mortality rate and 30-day unplanned readmission rate were calculated, with and without adjustment for patient age and comorbidity burden. Results Over 80% of these patients were cared for by a general medicine unit rather than a specialist unit. Patients admitted to a general medicine unit were, on average, 4 years older than those admitted to a respiratory unit. Comorbidity burdens were similar between units at the same hospital. Length of in-patient stay was >1 day shorter for those admitted to a general medicine unit, without significant compromise in mortality or readmission rates. Between each hospital, general medicine units showed a range of mortality rates and length of hospital stay, for which there was no obvious explanation. Conclusions Compared with speciality care, general medicine units can safely and efficiently care for patients presenting to hospital with community-acquired pneumonia. What is known about the topic? Within the narrow range of any specific disease, generalist medical services are often cited as inferior in performance compared with a speciality service. This has implications for hospital resourcing, including both staffing and ward allocation. What does this paper add? This paper demonstrates that most patients admitted with a principal diagnosis of community-acquired pneumonia were admitted to a generalist unit and did not apparently fare worse than patients admitted to a specialist service; patients admitted to a generalist unit spent less time in hospital and there was no difference in mortality or readmission rate compared with patients admitted to a specialist service. What are the implications for practitioners? The provision of generalist services at urban hospitals in Australia provides a safe alternative admission option for patients presenting with pneumonia, and possibly for other common acute medical conditions.

Exploring the care provided to mothers and children by community health workers in South Africa: missed opportunities to provide comprehensive care.

BACKGROUND: Community health workers (CHWs) provide maternal and child health services to communities in many low and middle-income countries, including South Africa (SA). CHWs can improve access to important health interventions for isolated and vulnerable communities. In this study we explored the performance of CHWs providing maternal and child health services at household level and the quality of the CHW-mother interaction. METHODS: A qualitative study design was employed using observations and in-depth interviews to explore the content of household interactions, and experiences and perceptions of mothers and CHWs. Fifteen CHWs and 30 mothers/pregnant women were purposively selected in three rural districts of KwaZulu-Natal, SA. CHW household visits to mothers were observed and field notes taken, followed by in-depth interviews with mothers and CHWs. Observations and interviews were audio-recorded. We performed thematic analysis on transcribed discussions, and content analysis on observational data. RESULTS: CHWs provided appropriate and correct health information but there were important gaps in the content provided. Mothers expressed satisfaction with CHW visits and appreciation that CHWs understood their life experiences and therefore provided advice and support that was relevant and accessible. CHWs expressed concern that they did not have the knowledge required to undertake all activities in the household, and requested training and support from supervisors during household visits. CONCLUSIONS: Key building blocks for a successful CHW programme are in place to provide services for mothers and children in households but further training and supervision is required if the gaps in CHW knowledge and skills are to be filled.

A newly designed observation and response chart's effect upon adverse inpatient outcomes and rapid response team activity.

BACKGROUND: Adverse inpatient events may diminish with earlier response to clinical deterioration. Observation and response charts with a tiered escalation response are recommended for use. AIMS: To examine the impact of an observation and response chart and altered calling criteria on rapid response team (RRT) calls, cardiac arrests and intensive care unit (ICU) admissions from the ward and hospital deaths. METHODS: Linked administrative and clinical data from an Australian, adult tertiary hospital for August 2007 to June 2013 (pre-chart) and July 2013 to December 2014 (post-chart) and analysed using interrupted time series analysis. RESULTS: Pre-chart RRT calls were increasing by 1.7 calls per 10 000 hospital admissions per month, whilst ICU admissions from the ward, deaths and cardiac arrests were decreasing by 0.3, 0.25 and 0.079 per 10 000 admissions per month respectively. Immediately upon chart introduction, the RRT call rate increased by 82% (66-98% CI; P < 0.01), the ward admissions to ICU rate increased by 41% (14-67% CI; P < 0.01) and the rates of deaths and cardiac arrests did not change. In the post chart period, both the pre-chart increasing trend in the rate of RRT and decreasing trend in the rate of ICU admissions changed significantly to become constant. The pre chart trends in the cardiac arrest rate and hospital mortality did not change. CONCLUSION: Observation and response charts increased RRT and ICU workload without improving cardiac arrest rate or mortality. Future chart evaluation should identify features beneficial to patient outcomes and refine those that consume critical care resources that are not associated with improved patient outcomes.

Impact of the emergency department streaming decision on patients' outcomes.

BACKGROUND: Streaming occurs in emergency department (ED) to reduce crowding, but misallocation of patients may impact patients' outcome. AIM: The study aims to determine the outcomes of patients misallocated by the ED process of streaming into likely admission or discharge. METHODS: This is a retrospective cohort study, at an Australian, urban, tertiary referral hospital's ED between January 2010 and March 2012, using propensity score matching for comparison. Total and partitioned ED lengths of stay, inpatient length of stay, in-hospital mortality and 7- and 28-day unplanned readmission rate were compared between patients who were streamed to be admitted against those streamed to be discharged. RESULTS: Total ED length of stay did not differ significantly for admitted patients if allocated to the wrong stream (median 7.6 h, interquartile range 5.7-10.6, cf. 7.5 h, 5.3-11.2; P = 0.34). The median inpatient length of stay was shorter for those initially misallocated to the discharge stream (1.8 days, 1.1-3.0, cf. 2.4 days, 1.4-3.9; P < 0.001). In-hospital mortality and 7- and 28-day readmission rates were not adversely affected by misallocation. When considering patients eventually discharged from the ED, those allocated to the wrong stream stayed in the ED longer than those appropriately allocated (5.2 h, 3.7-7.3, cf. 4.6 h, 3.3-6.4; P < 0.001). CONCLUSION: There were no significant adverse consequences for an admitted patient initially misallocated by an ED admission/discharge streaming process. Patients' discharge from the ED was slower if they had been allocated to the admission stream. Streaming carries few risks for patients misallocated by such a process.

Variability in inpatient serum creatinine: its impact upon short- and long-term mortality.

BACKGROUND: Long-staying medical inpatients carry a significant burden of acute and chronic illness. Prediction of their in-hospital and longer-term mortality risk is important. AIM: The aim of this study was to determine to what extent creatinine variability predicts in-hospital and 1-year mortality in inpatients. DESIGN: Retrospective cohort analysis. METHODS: Patients were included if aged 18 years or older and if admitted for 7 days or longer. The main outcome variables were mortality in hospital and after discharge. RESULTS: Increasing age, the presence of heart failure and a reduced estimated glomerular filtration rate (eGFR) on admission (<60 ml/min/1.73 m(2)) all associated with death risk (both in hospital and within a year of discharge). The creatinine change was related to mortality risk for the patient whilst in hospital and within 1 year after discharge independently of these other factors. The threshold of creatinine change, above which the in-hospital mortality rose significantly was 25 µmol/l (P < 0.001). A creatinine change of >10 µmol/l predicted significantly higher mortality within a year of discharge (P < 0.001). Every 5 µmol/l change in creatinine was associated with an in-hospital mortality increase of 3% (P < 0.001) and a 1-year mortality increase of 1% (P < 0.007). CONCLUSIONS: Patients with a creatinine rise or fall of >10 µmol/l during admission are at higher risk of death after discharge than those with more stable creatinine. These patients therefore merit further attention that might include more focused nutritional assessment, cardiovascular risk factor management or advance care planning.

Prevention of mother to child transmission of HIV (PMTCT) programme in KwaZulu-Natal, South Africa: an evaluation of PMTCT implementation and integration into routine maternal, child and women's health services.

OBJECTIVES: To evaluate prevention of mother to child transmission of HIV (PMTCT) implementation and integration of PMTCT with routine maternal and child health services in two districts of KwaZulu-Natal; to report PMTCT coverage, to compare recorded and reported information, and to describe responsibilities of nurses and lay counsellors. METHODS: Interviews were conducted with mothers in post-natal wards (PNW) and immunisation clinics; antenatal and child health records were reviewed. Interviews were conducted with nurses and lay counsellors in primary health care clinics. RESULTS: Eight hundred and eighty-two interviews were conducted with mothers: 398 in PNWs and 484 immunisation clinics. During their recent pregnancy, 98.6% women attended antenatal care (ANC); 60.8% attended their first ANC in the third trimester, and 97.3% were tested for HIV. Of 312 mothers reporting themselves HIV positive during ANC, 91.3% received nevirapine, 78.2% had a CD4 count carried out, and 33.1% had a CD4 result recorded. In the immunisation clinic, 47.6% HIV-exposed babies had a PCR test, and 47.0% received co-trimoxazole. Of HIV-positive mothers, 42.1% received follow-up care, mainly from lay counsellors. In 12/26 clinics, there was a dedicated PMTCT nurse, PCR testing was not offered in 14/26 clinics, and co-trimoxazole was unavailable in 13/26 immunisation clinics. Nurses and lay counsellors disagreed about their roles and responsibilities, particularly in the post-natal period. CONCLUSIONS: There is high coverage of PMTCT interventions during pregnancy and delivery, but follow-up of mothers and infants is poor. Poor integration of PMTCT services into routine care, lack of clarity about health worker roles and poor record keeping create barriers to accessing services post-delivery.

Diagnosis of paediatric HIV infection in a primary health care setting with a clinical algorithm.

OBJECTIVE: To determine the validity of an algorithm used by primary care health workers to identify children with symptomatic human immunodeficiency virus (HIV) infection. This HIV algorithm is being implemented in South Africa as part of the Integrated Management of Childhood Illness (IMCI), a strategy that aims to improve childhood morbidity and mortality by improving care at the primary care level. As AIDS is a leading cause of death in children in southern Africa, diagnosis and management of symptomatic HIV infection was added to the existing IMCI algorithm. METHODS: In total, 690 children who attended the outpatients department in a district hospital in South Africa were assessed with the HIV algorithm and by a paediatrician. All children were then tested for HIV viral load. The validity of the algorithm in detecting symptomatic HIV was compared with clinical diagnosis by a paediatrician and the result of an HIV test. Detailed clinical data were used to improve the algorithm. FINDINGS: Overall, 198 (28.7%) enrolled children were infected with HIV. The paediatrician correctly identified 142 (71.7%) children infected with HIV, whereas the IMCI/HIV algorithm identified 111 (56.1%). Odds ratios were calculated to identify predictors of HIV infection and used to develop an improved HIV algorithm that is 67.2% sensitive and 81.5% specific in clinically detecting HIV infection. CONCLUSIONS: Children with symptomatic HIV infection can be identified effectively by primary level health workers through the use of an algorithm. The improved HIV algorithm developed in this study could be used by countries with high prevalences of HIV to enable IMCI practitioners to identify and care for HIV-infected children.

The assessment of disability in patients on an acute medical ward for elderly people.

The level of independence in self-care was monitored weekly in 212 patients admitted over 6 months to an acute medical ward for elderly people, and documented on discharge using a standard assessment, the Barthel Index. At discharge from the admitting ward, 39% of patients were independent (Barthel score of 20), 36% were mildly dependent (Barthel 15-19), 15% were moderately dependent (Barthel 10-14), 4% severely dependent (Barthel 5-9) and 6% very severely dependent (Barthel 0-4). Approximately 80% were able to transfer, walk, were continent of urine and could wash their top half, but one-third were unable to dress or use the toilet independently. Over half were unable to bath themselves or climb stairs unaided. It is feasible to assess disability in a busy acute service this way. Information can be provided both to community services on discharge of individual patients, and to managers responsible for planning services for elderly people.

The organically handicapped child. How can the family physician help?

The better his understanding of some of the ways in which an organic deficit might affect normal development of the handicapped child, the more able the family physician will be to offer guidance to the family aimed at preventing the development of secondary problems. He can thus be instrumental in helping a child achieve his maximal potential.First, it is important to take into account how the parents' emotional and intellectual responses to having a defective child may interfere markedly in normal parent-child relationship. Second, ways in which each deficit will limit a child's exposure to stimuli must not be over-looked. Third, one must consider how a deficit may indirectly distort the normal learning patterns when parents do not make age appropriate demands. Fourth, it is important to understand how specific interference in the area of language skills may cause further developmental retardation. Fifth, one must be aware of special problems that an organically handicapped child must face in the society outside of the family. Last of all, in an older child, one must consider the need for a full scale evaluation to sort out primary and secondary factors in the picture.