Inter-hospital transfers of patients with systemic lupus erythematosus: characteristics, predictors, and outcomes

OBJECTIVE: To describe the reasons for inter-hospital transfers of patients with systemic lupus erythematosus (SLE), to identify predictors of transfers, and to compare the risk of in-hospital mortality between patients who were transferred and those not transferred. METHODS: Data on acute care hospitalizations of patients with SLE in New York and Pennsylvania in 2000-2002 were obtained from state health planning agencies. We identified inter-hospital transfers from discharge and admission codes, and categorized the major reason for transfer (rehabilitation, procedure, or continued medical care). Patient and hospital characteristics were examined as predictors of transfers. We used a matched cohort design with propensity adjustment to compare in-hospital mortality between patients transferred for continued medical care and those who were not transferred. RESULTS: We identified 533 inter-hospital transfers in 490 patients, 524 of which involved one transfer per hospitalization episode. Of these 524 transfers, 122 (23.3%) were for rehabilitation, 158 (30.1%) were for procedures, and 244 (46.6%) were for continued medical care. Patient characteristics and transfer destinations varied among these groups. Transfers for continued medical care were more common among younger patients, those who were more severely ill, had an emergency or urgent admission, or were hospitalized in a smaller, rural or non-teaching hospital, or in Pennsylvania, and were less common among those at proprietary hospitals. In the matched cohort analysis, the risk of in-hospital mortality was 2.25 times higher (95% confidence interval 1.31, 3.85; p = 0.004) among those transferred compared with those who were not transferred. This risk differed with the experience of the attending physician at the receiving hospital: among patients of physicians who treated 3 or fewer patients with SLE per year, this risk was 2.5 times higher (95% CI 1.42, 4.36; p = 0.002), while among patients of physicians who treated more than 3 patients with SLE per year, this risk was 0.56 times (95% CI 0.06, 5.12; p = 0.62) that of matched controls. CONCLUSION: Patient and transferring hospital characteristics vary with the reason for transfer. Transfers for continued medical care are associated with higher risks of in-hospital mortality, but these risks may differ with the SLE-related experience of the attending physician at the receiving hospital.     

Ethnic and socioeconomic disparities in health among patients with rheumatic disease

PURPOSE OF REVIEW: To describe recent studies of differences in the occurrence and outcomes of rheumatic diseases and differences in treatment by ethnic group or socioeconomic status. RECENT FINDINGS: African Americans and Hispanics in the United States have consistently been found to have higher prevalences of arthritis and other rheumatic conditions than whites, and also generally have more activity limitations in the setting of rheumatic disease. Variations in disease occurrence by socioeconomic status have not been studied extensively. African Americans with osteoarthritis were less likely than whites to be treated with narcotic analgesics. Rates of total knee or hip arthroplasty were found to be substantially lower among African Americans and Hispanics than among whites in the United States, and lower among those of low socioeconomic status in the United Kingdom. Ethnic differences in use of arthroplasty have been associated with less willingness of African Americans to have surgery, which has been related to perceptions of uncertain benefits of surgery. Poverty and ethnicity had important associations with the activity of systemic lupus erythematosus, whereas socioeconomic status was a more important predictor of mortality in these patients. Treatment adherence was similar in African American and white patients with systemic lupus erythematosus, but barriers to adherence differed by ethnic group. SUMMARY: Ethnic disparities in health have been more extensively studied than socioeconomic disparities. Most studies only describe the disparities, but several studies have begun to investigate potential reasons for the disparities.     

Management of extensive cutaneous necrosis due to meningococcal septicaemia purpura fulminans with topical negative pressure (TNP) suits

Extensive cutaneous necrosis due to purpura fulminans presents many of the same treatment challenges as a significant burn injury. The areas of tissue loss are large, require complex and repeated dressings and create a significant reconstructive challenge. These patients are therefore often treated by burns multi-disciplinary teams (Ariivalo et al., Burns 24:272–274, 1). Topical negative pressure (TNP) therapy has a recognised role in the management of complex wounds, but its use is normally restricted to moderates sized defects. This paper describes a method of TNP dressing application to large purpura fulminans wound areas, including the buttocks and perineum, by fashioning ATNP suits. A photographically illustrated series is presented to demonstrate a TNP suit application in four consecutive paediatric cases of severe purpura fulminans, and they are representative of our practise. These cases illustrate how TNP suits provide a robust movement resistant dressing which removes exudate from the wound, splinting and reducing the wound area, promoting a graftable bed and facilitating graft take in these difficult to manage patients.     

Central nervous system activity of the methanol extract of Ficus platyphylla stem bark

The central nervous system (CNS) activity of the methanolic extract of Ficus platyphylla stem bark was studied on locomotor activity, pentobarbital sleeping time, exploratory behaviour, amphetamine-induced hyperactivity, apomorphine-induced stereotypy, active-avoidance and performance on tread mills (rota-rod), using mice and rats. The results revealed that the extract significantly reduced the locomotor and exploratory activities in mice, prolonged pentobarbital sleeping time in rats, attenuated amphetamine-induced hyperactivity and apomorphine-induced stereotypy in mice, dose-dependently. The extract significantly suppressed the active-avoidance response in rats, with no significant effect on motor co-ordination as determined by the performance on rota-rod. The results suggest that the extract may possess sedative principles with potential neuroleptic properties.     

Neuropharmacological effects of the aqueous extract of Nauclea latifolia root bark in rats and mice

The present study evaluated the neuropharmacological effects of the aqueous extract of Nauclea latifolia root bark in rodents. Effects on the spontaneous motor activity (SMA), exploratory behaviour, pentobarbital sleeping time, apomorphine-induced stereotypic behaviour and motor coordination (rota-rod performance) were investigated. The extract (50-200 mg/kg p.o.) significantly (P<0.05) decreased the SMA and exploratory behaviour in mice and prolonged pentobarbital sleeping time in rats dose-dependently. The extract also remarkably attenuated the intensity of apomorphine-induced stereotypy dose-dependently in mice, but had no effect on motor coordination as determined by the performance on rota-rod. These results indicate the presence of psychoactive substances in the aqueous extract of the root bark of Nauclea latifolia.     

Validation of English and Spanish-language versions of a screening questionnaire for rheumatoid arthritis in an underserved community

OBJECTIVE: Questionnaires to screen for rheumatoid arthritis (RA) have been tested in groups that were primarily well educated and Caucasian. We sought to validate the RA questions of the Connective Tissue Disease Screening Questionnaire (CSQ) in ethnic minorities in an underserved community, and to test a Spanish-language version. METHODS: The Spanish-language version was developed by 2 native speakers. Consecutive English-speaking or Spanish-speaking patients in a community-based rheumatology practice completed the questionnaire. Diagnoses were confirmed by medical record review. Sensitivity and specificity of the questionnaire for a diagnosis of RA were computed for each language version, using 2 groups as controls: patients with noninflammatory conditions, and participants recruited from the community. RESULTS: The English-language version was tested in 53 patients with RA (79% ethnic minorities; mean education level 11.3 yrs), 85 rheumatology controls with noninflammatory conditions, and 82 community controls. Using 3 positive responses as indicating a positive screening test, the sensitivity of the questionnaire was 0.77, the specificity based on rheumatology controls was 0.45, and the specificity based on community controls was 0.94. The Spanish-language version was tested in 55 patients with RA (mean education level 7.8 yrs), 149 rheumatology controls, and 88 community controls. The sensitivity of the Spanish-language version was 0.87, with specificities of 0.60 and 0.97 using the rheumatology controls and community controls, respectively. CONCLUSION: The sensitivity of the English-language version of the RA questions of the CSQ was lower in this study than in other cohorts, reflecting differences in the performance of the questions in different ethnic or socioeconomic groups. The Spanish-language version demonstrated good sensitivity, and both had excellent specificity when tested in community controls.