Incidence and predictors of hospital readmission in children presenting with severe anaemia in Uganda and Malawi: a secondary analysis of TRACT trial data

Background: Severe anaemia (haemoglobin < 6 g/dL) is a leading cause of recurrent hospitalisation in African children. We investigated predictors of readmission in children hospitalised with severe anaemia in the TRACT trial (ISRCTN84086586) in order to identify potential future interventions. Methods: Secondary analyses of the trial examined 3894 children from Uganda and Malawi surviving a hospital episode of severe anaemia. Predictors of all-cause readmission within 180 days of discharge were identified using multivariable regression with death as a competing risk. Groups of children with similar characteristics were identified using hierarchical clustering. Results: Of the 3894 survivors 682 (18%) were readmitted; 403 (10%) had ≥2 re-admissions over 180 days. Three main causes of readmission were identified: severe anaemia (n = 456), malaria (n = 252) and haemoglobinuria/dark urine syndrome (n = 165). Overall, factors increasing risk of readmission included HIV-infection (hazard ratio 2.48 (95% CI 1.63–3.78), p < 0.001); ≥2 hospital admissions in the preceding 12 months (1.44(1.19–1.74), p < 0.001); history of transfusion (1.48(1.13–1.93), p = 0.005); and missing ≥1 trial medication dose (proxy for care quality) (1.43 (1.21–1.69), p < 0.001). Children with uncomplicated severe anaemia (Hb 4-6 g/dL and no severity features), who never received a transfusion (per trial protocol) during the initial admission had a substantially lower risk of readmission (0.67(0.47–0.96), p = 0.04). Malaria (among children with no prior history of transfusion) (0.60(0.47–0.76), p < 0.001); younger-age (1.07 (1.03–1.10) per 1 year younger, p < 0.001) and known sickle cell disease (0.62(0.46–0.82), p = 0.001) also decreased risk of readmission. For anaemia re-admissions, gross splenomegaly and enlarged spleen increased risk by 1.73(1.23–2.44) and 1.46(1.18–1.82) respectively compared to no splenomegaly. Clustering identified four groups of children with readmission rates from 14 to 20%. The cluster with the highest readmission rate was characterised by very low haemoglobin (mean 3.6 g/dL). Sickle Cell Disease (SCD) predominated in two clusters associated with chronic repeated admissions or severe, acute presentations in largely undiagnosed SCD. The final cluster had high rates of malaria (78%), severity signs and very low platelet count, consistent with acute severe malaria. Conclusions: Younger age, HIV infection and history of previous hospital admissions predicted increased risk of readmission. However, no obvious clinical factors for intervention were identified. As missing medication doses was highly predictive, attention to care related factors may be important. Trial registration: ISRCTN ISRCTN84086586. Keywords: Severe anaemia, Readmissio

The value of the pediatric urgent care in pediatric resident education

Introduction: Pediatric urgent care (UC) is a growing field and may provide unique learning opportunities for pediatric residents. We aimed to assess whether a UC rotation could be feasible and meaningful and help fill educational gaps. Methods: Within our current X+Y rotational model, we used Kern\u27s six-step approach for curriculum development to create a longitudinal UC educational experience for post-graduate year 2 (PGY 2) pediatric residents. We assessed progress towards achieving our aim by using a mixed-methods approach matched to Kirkpatrick\u27s levels of learning, including program annual evaluations, self-assessed UC competencies and 360 milestone evaluations. Results: Fourteen PGY 2s participated in our yearlong longitudinal rotation without duty hour violations or deviations from well childcare. Thematic analysis revealed concepts of autonomy, procedural access, and intentionality of education. Residents showed statistical improvement in 4/10 milestones and 26/27 self-assessed performance items. Six of 14 residents scored ≥ 4 on all milestones by the end of the year. Discussion: Our curriculum demonstrates a valuable role for the pediatric urgent care in the procedural and clinical education of pediatric residents. Practical implications and assessment tools of such a curriculum may be valuable for others interested in integrating this learning experience into their current educational model

Activating Controlling Images in the Racialized Interaction Order: Black Middle-Class Interactions and the Creativity of Racist Action

This paper investigates the link between the racial hierarchy and the racialized interaction order, questioning how controlling images of blackness are mediated in interactions. I explore this through interviews with 32 black British middle-class individuals, examining their interactions in the professional workplace. I argue that white people often draw on a practical knowledge of “white ignorance” to activate controlling images in their interactions with black professionals. This white ignorance allows for white people to find creative ways to irrationally deploy controlling images, and to adapt controlling images to specific interactional settings