Understandings and experiences of dementia in Fiji

Karen Johnston investigated the experiences of dementia in Fiji from the perspectives of multiple stakeholders. She constructed a grounded theory about processes that caregivers use to manage dementia care, 'letting it be'. Positive change centres on the integration and promotion of community understandings and cultural values with service provision

Outcomes of adolescents and younger adults who have mechanical valve replacement surgery for rheumatic heart disease in a low-middle-income country

Background: Rheumatic heart disease (RHD) is a progressive chronic health condition characterised by damaged heart valves and predominantly occurs in younger adults in low and middle income countries (LMICs). Replacement of the damaged heart valve/s improves patient outcomes, however mechanical valves are often used in LMIC, so ongoing medical monitoring and self-care are required. The Fiji Islands is a LIMC with one of the highest rates of RHD in the world and valve replacement (VR) is often undertaken by humanitarian fly‑in/fly‑out surgical teams. Open Heart International (OHI), is one such team, which has been conducting VR surgery for RHD in Fiji since 1991. Aims: Identify the short and long-term outcomes of mechanical VR surgery for RHD in Fiji since 1991. Specifically: 1) Determine the mortality and morbidity outcomes and identify independent predictors of these outcomes; 2a) Determine what is globally known about the HRQoL of younger mechanical VR patients through an integrative literature review; 2b) Determine pre-and post-operative HRQoL of patients who have VR surgery by OHI and identify independent predictors of these outcomes; and, 3) Determine anticoagulation adherence and predictors of non-adherence of patients who had VR surgery by OHI. Methods: 1) Morbidity and mortality data were collected through medical record audit on all patients (n = 167) with records available on mortality for 149 (89.2% patients, and morbidity for 152 (91%) patients. 2a) A systematic search of the electronic bibliographic databases OVIDMedline, PyscINFO(OVID), PubMED, CINAHL(EBSCO), ProQuest Health & Medicine, Cochrane Library(Wiley), and Google Scholar for studies published between January 2000 and April 2013 was undertaken on HRQoL outcomes post mechanical VR in patients aged < 65 years. 2b) a cross-sectional study of HRQoL was undertaken of patients who had surgery from 1991-2009 (n=72) and pre- and/or post-operatively (mean follow-up time 5.9 years) in patients undergoing surgery from 2010-2013 (n = 56) using the standard SF-36 (v2) survey. 3) Aspects of antithrombotic health self-management were evaluated using a cross-sectional survey study. Results: 1) Patients having VR delivered by the OHI team had 26% mortality and morbidity over the 20 year period at a mean age of 26 years. Half of all mortality and a quarter of all morbidity occurred in the first year postoperatively, with the major causes of both being related to anticoagulation and an absence of RHD-prophylaxis. Females required more hospital admissions for heart failure, were significantly more vulnerable to major adverse outcomes including bleeding and cerebral events, and were three times more likely to die prematurely. 2a) The systematic literature review indicated that post-VR surgery individuals can expect sustained and improved HRQoL, although lower HRQoL occurred in younger people, those in resource-limited regions, and evaluations of factors that may potentially impact HRQoL, such as valve-specific health self-management requirements. 2b) Overall HRQoL outcomes improved substantially for the majority of individuals. Clinically significant decline in mental health domains occurred at one year; domains related to physicality and emotional health significantly declined at two years; and overall, males were independently at risk of impairment in emotional health. 3) Mechanical VR ongoing medical support issues were evident, with more than two-thirds of the younger adults not commenced/re-commenced on postoperative RHD prophylaxis, a quarter reported poor adherence to their warfarin regime, and 13.38% (n=17) had self-ceased warfarin completely. Younger age was strongly associated with poor adherence to warfarin; however, lack of knowledge, routinely forgetting to take warfarin, and a longer travel time to the heart clinic was strongly associated with eventual complete self-cessation of warfarin. Conclusions: This research highlights the important role of Fly In/Fly Out teams in providing VR surgery for people affected by RHD in the LMIC of Fiji. Substantial and ongoing benefits were evident in mortality, morbidity and HRQoL. However, the need for increased surveillance, targeted preoperative education and continued and evolving postoperative education that meets the needs of younger people was also identified. Being a resource-limited country, a sustainable source of funding is unlikely in the short term, and therefore exploring ways that existing health professionals, such as nurses, could be better utilised for increased patient surveillance, support and education is indicated. Engagement with Ministry of Health and the wider medical and nursing workforce is necessary to ensure that once the surgical team departs, these young people remain prioritised. Further research is needed to identify reasons for disparities in gender outcomes and strategies to address this

Different data approaches to improving chronic kidney disease treatment and outcomes

Chronic kidney disease (CKD) affects more than 1/10 people worldwide with a disproportionately high burden in disadvantaged communities. As CKD severity increases, the associated morbidity, mortality and treatment costs also increase. In the case of kidney failure, the most severe form of CKD, the costs of treatment, including life prolonging treatment with dialysis or kidney transplant, are often unaffordable in under-resourced healthcare settings. Data has been central to improving the outcomes of patients with CKD, but there continue to be important data gaps, especially in low- and lower-middle-income countries (LLMICs). In order to more comprehensively understand the burden of kidney disease, it is necessary to overcome the many challenges to data collection which exist globally. To explore how this could be achieved, this thesis examines how four different data sources can contribute to addressing gaps in understanding CKD. Firstly, the role of kidney replacement therapy (KRT) registries in LLMICs were assessed through a review of the literature and explored further by implementing a dialysis registry in Fiji. Secondly, extending data collection of a randomised controlled trial to examine how differing practice patterns across regions might impact outcomes was assessed through analysis of the extended follow-up of the Study of Heart and Renal Protection (SHARP). Thirdly, the role of administrative data was explored through a literature review and through two novel data linkage analyses. Lastly, semi-structured interviews were conducted with patients and clinicians to understand their perspectives on remote patient monitoring (RPM), a novel approach to patient data collection for dialysis treatment. The analyses examining the role of focused KRT registries in LLMICs and the utility of long-term follow-up of clinical trials to compare outcomes between regions suggest that whilst useful at describing the burden of disease and treatment, these data sources are unlikely to be central to solving major knowledge gaps due to their cost and complexity. The use of administrative data and data linkage offer an opportunity for efficient data collection in CKD and may represent a cost-effective investment for developing healthcare systems in the future. Novel data capture techniques, such as RPM, may improve CKD data collection, but a thorough understanding of the perspectives of user populations should be considered before their wider implementation

The Coconut Tree and the Computer Tiger: Information Technology in Traditional Pacific Societies

This literature review explores the extent to which Information Technology (IT) has affected the cultures of small traditional Pacific societies, with the South Pacific region as the point of focus. The assumption is that the educational systems of Pacific nations are in the developmental stage with the associated sophisticated technological applications. The thesis asks what if any, cultural challenges of adopting information technology have arisen? The review finds that traditional culture and information technology are in competition in the power stakes of human consideration, reflected in South Pacific indigenous academics seeking independence as researchers and acceptance in their own right. The realisation that culture and technology need to function together requires attaining academic freedom in the aftermath of post-colonial restrictions placed on the indigenous sociological and anthropological imagination. The first part examines the history of information technology generally, and the significance of work already done, providing a perspective of how the subject has developed and become established, assisting in the development and acquisition of the appropriate vocabulary. The review explains and describes the occurrence of information technology in the South Pacific, the effect of globalisation and shared knowledge through ethno-methodology, every day culture in action, describing the ways in which people make the sense they do and through the ways they communicate. In the second part the focus is on the detail of the commonsense character of everyday life and the practices by which they make their actions understandable by others. Scrutiny of how people do what they do provides an explanation of what those people do and why they do it in the way they do. Western form of governance is a reality, with nation building based on Western models of development. National independence and sovereignty with a wave of neo-colonialism and aid dependency led to economic globalisation, with resentment against value systems that erode indigenous values, producing a wave of re-indigenisation facilitated by the revolution known as information technology . There is a coherent body of Pacific thought, with a shared philosophy and ethic on the public agenda. In the material covered, elements standing out are the awareness among growing numbers of Pacific academics of the need for a genuine and far-reaching contextualisation, acknowledging the relevance and applicability of indigenous cultural values in contemporary settings. Second is the success of communities whose initiatives have followed familiar traditional ways they know and understand, reaping rewards. The region has development and governance failures in Papua New Guinea, Solomon Islands and Fiji to name a few; the national state of affairs in some countries is not encouraging. Where good development and governance are occurring, it is usually through the direct initiative of local communities using their knowledge base. The information upheaval is creating new opportunities in the lives of people from small traditional societies. Information Technology expands throughout the social structure of the Pacific in direct proportion to personal computer access literally at one's finger tips

Rheumatic fever and rheumatic heart disease among children presenting to two referral hospitals in Harare, Zimbabwe

Background. Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain significant causes of morbidity and mortality in resource-limited settings. In Zimbabwe ARF/RHD characteristics have not been systematically documented.Objectives. To document cases of ARF/RHD among children presenting at referral hospitals in Harare, Zimbabwe, determine their clinical and echocardiographic characteristics, and identify opportunities for improving care.Methods. A cross-sectional survey was carried out in which consecutive children aged 1 - 12 years presenting with ARF/RHD according to the 2002/3 World Health Organization modified Jones criteria were enrolled.Results. Out of 2 601 admissions and 1 026 outpatient visits over 10 months, 50 children were recruited, including 31 inpatients with ARF/RHD and 19 outpatients with chronic RHD. Among inpatients, 9 had ARF only, 7 recurrent ARF with RHD, and 15 RHD only. The commonest valve lesions were mitral regurgitation (26/31) and aortic regurgitation (11/31). The commonest reason for admission was cardiac failure (22/31). The proportion of ARF/RHD cases among inpatients aged 1 - 12 years was 11.9/1 000. Of the 22 with RHD, 14 (63.6%) presented de novo and 1 had bacterial endocarditis. Among the outpatients, 15 had  cardiac failure while echocardiographic findings included mitral regurgitation (18/19) and aortic regurgitation (5/19). At presentation, 18/26 known cases were on oral penicillin prophylaxis and 7 on  injectable penicillin. Of those on secondary prophylaxis, 68.0% reported taking it regularly.Conclusion. ARF/RHD remains a major problem and cause of hospital admissions in Harare, Zimbabwe. Children often present late with established RHD and cardiac failure. With the majority on oral penicillin, secondary prophylaxis was suboptimal in a resource-limited setting unable to offer valve replacement surgery

Rheumatic fever and rheumatic heart disease among children presenting to two referral hospitals in Harare, Zimbabwe

Background. Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain significant causes of morbidity and mortality in resource-limited settings. In Zimbabwe ARF/RHD characteristics have not been systematically documented.Objectives. To document cases of ARF/RHD among children presenting at referral hospitals in Harare, Zimbabwe, determine their clinical and echocardiographic characteristics, and identify opportunities for improving care. Methods. A cross-sectional survey was carried out in which consecutive children aged 1 - 12 years presenting with ARF/RHD according to the 2002/3 World Health Organization modified Jones criteria were enrolled.Results. Out of 2 601 admissions and 1 026 outpatient visits over 10 months, 50 children were recruited, including 31 inpatients with ARF/RHD and 19 outpatients with chronic RHD. Among inpatients, 9 had ARF only, 7 recurrent ARF with RHD, and 15 RHD only. The commonest valve lesions were mitral regurgitation (26/31) and aortic regurgitation (11/31). The commonest reason for admission was cardiac failure (22/31). The proportion of ARF/RHD cases among inpatients aged 1 - 12 years was 11.9/1 000. Of the 22 with RHD, 14 (63.6%) presented de novo and 1 had bacterial endocarditis. Among the outpatients, 15 had cardiac failure while echocardiographic findings included mitral regurgitation (18/19) and aortic regurgitation (5/19). At presentation, 18/26 known cases were on oral penicillin prophylaxis and 7 on injectable penicillin. Of those on secondary prophylaxis, 68.0% reported taking it regularly. Conclusion. ARF/RHD remains a major problem and cause of hospital admissions in Harare, Zimbabwe. Children often present late with established RHD and cardiac failure. With the majority on oral penicillin, secondary prophylaxis was suboptimal in a resource-limited setting unable to offer valve replacement surgery.

Epidemiology of intussusception before and after rotavirus vaccine introduction in Fiji.

In 2012, Fiji introduced rotavirus vaccine (Rotarix, GSK) into the national immunisation schedule. We describe the intussusception epidemiology prior to rotavirus vaccine, temporal association of intussusception cases to administration of rotavirus vaccine, and estimate the additional number of intussusception cases that may be associated with rotavirus vaccine. A retrospective review of intussusception cases for children aged <24 months old was undertaken between January 2007 and October 2012 pre-vaccine. All admissions and deaths with a discharge diagnosis of intussusception, bowel obstruction, paralytic ileus, or intussusception ICD10-AM codes were extracted from national databases and hospital records. Nationwide active intussusception surveillance was established for three years post-vaccine (2013-2015). There were 24 definite intussusception cases in the pre-rotavirus vaccine period, 96% were confirmed by surgery. The median age was 6.5 months. The incidence rate was 22.2 (95% CI: 13.9-33.7) per 100,000 infants. There were no deaths. Active surveillance identified 25 definite intussusception cases, 96% of which were among children who were age-eligible for rotavirus vaccine. None were potentially vaccine related. We estimated one to five additional  cases of intussusception every five years. The incidence of intussusception pre-rotavirus vaccine in Fiji is low. Intussusception associated with rotavirus vaccine is likely a rare event in Fiji