Rheumatic heart disease in pregnancy : gaps and facilitators of care

University of Technology Sydney. Faculty of Health.In the twenty-first century, rheumatic heart disease (RHD) persists in low- and middle-income countries as well as vulnerable populations in high-income countries, particularly Indigenous peoples. RHD in pregnancy (RHD-P) is associated with an increased burden of maternal mortality and morbidity, poorer perinatal outcomes, and compromised care pathways. There is inadequate knowledge regarding models of care for women with RHD-P. This research identifies and examines gaps and facilitators of optimal care for women with RHD-P with a focus on Australian health services. The mixed methods research employed a transformative parallel design lens, providing a mechanism with which to address the political and social complexities of research in the RHD-P arena and in turn establishing a framework for change. The study comprises three elements. The first involved a systematic review and qualitative synthesis of the peer-reviewed literature, that explored approaches to care provision for women with RHD-P and examine reported measures. It applied content analysis to examine models of care and clinical care reporting measures. The second element entailed a descriptive qualitative study that explored 19 health professionals’ perspectives of care pathways for women with RHD-P. The semi-structured interviews were analysed thematically. The final study conducted a process evaluation of the implementation of a population-based study of RHD-P in Australia. It examined the operationalising of the research project, and evaluated strategies developed to strengthen reporting and improve awareness of the impact of RHD during pregnancy among health services. The studies identified gaps related to health systems, health workforces and health information that impacted on effective models of care. The systematic review found that key reporting measures in studies that refer to RHD-P were poorly recorded. The qualitative study of health professionals’ perspectives of RHD-P identified a constellation of factors that challenged the provision of cohesive women-centred health care. Themes included - helping to break down silos of information, processes and access; ‘ ’ – reflecting the complexity of care issues; and – factors that contributed to improved understandings of disease, informed decision-making, and the inclusion of family and community members. The process evaluation of the population level study of RHD-P exemplified several of the themes arising from the previous two studies. Effective reporting was negatively impacted by a lack of diagnostic certainty; incompatible health information systems and varying clinical awareness among health professionals. This research found that, despite often complex care requirements, pregnancy for women with RHD provides a unique opportunity to strengthen health system responses, improve care pathways, address whole of life health and ultimately reduce the burden of RHD for women. To respond effectively, structural and cultural changes are required to improve health system agility and capability. This includes enhanced investment in education and capacity building – particularly in maternal health – to support a better informed and skilled workforce; and improved information systems and reporting of core indicators to more accurately benchmark care pathways, outcomes and burden of RHD-P. Central to the provision of informed, respectful collaborative care for women with RHD is timely diagnosis, access to health services and continuity of care. The research recommendations based on study findings aim to better achieve these goals and, in doing so, ensure the needs of vulnerable women with RHD are better met

Cultural Identity as a Determinant of Health among South Sudanese in Sydney, Australia

Background. The issue of identity has been widely explored among migrant populations in western countries in the context of cultural integrations and acculturations. However, there is less evidence on identity as a determinant of health and social wellbeing. This study reports on identity as a determinant of health among the South Sudanese community who arrived as refugees through an Australian humanitarian program in the early 2000s. Methods. A qualitative study was undertaken, underpinned by a phenomenological framework that characterised the lived experiences of adult South Sudanese in Sydney, Australia. Semistructured in-depth interviews explored how 26 participants identified themselves in Australia, including changes in their experiences over time, their social and general life situation in Australia, and how they felt perceived in Australia. Data were audio-recorded using a digital voice recorder, transcribed verbatim, coded, and categorised into themes using interpretive thematic analysis. Results. Participants described a multiplicity of interconnected domains that governed the negotiating and making sense of identity, in turn mediated by other interwoven personal and structural factors that shaped experience and perception. Expressions of hope, pride, and achievement were threaded through several of the interviews, particularly in relation to their children. There were also frustrations related to employment challenges and discrimination that limited identity ownership. Conclusions. The evolving and often conflicting factors identified by participants can shape their sense of belonging, integration, and social and mental wellbeing. A deeper, more nuanced understanding of bicultural identity within a strengths-based framework is needed, with improved partnerships and services to support and strengthen South Sudanese community integration, belonging, and acculturation in Australia

Maternal super-obesity and perinatal outcomes in Australia: A national population-based cohort study

Background: Super-obesity is associated with significantly elevated rates of obstetric complications, adverse perinatal outcomes and interventions. The purpose of this study was to determine the prevalence, risk factors, management and perinatal outcomes of super-obese women giving birth in Australia. Methods: A national population-based cohort study. Super-obese pregnant women (body mass index (BMI) >50 kg/m2 or weight >140 kg) who gave birth between January 1 and October 31, 2010 and a comparison cohort were identified using the Australasian Maternity Outcomes Surveillance System (AMOSS). Outcomes included maternal and perinatal morbidity and mortality. Prevalence estimates calculated with 95 % confidence intervals (CIs). Adjusted odds ratios (ORs) were calculated using multivariable logistic regression. Results: 370 super-obese women with a median BMI of 52.8 kg/m2 (range 40.9–79.9 kg/m2) and prevalence of 2.1 per 1 000 women giving birth (95 % CI: 1.96–2.40). Super-obese women were significantly more likely to be public patients (96.2 %), smoke (23.8 %) and be socio-economically disadvantaged (36.2 %). Compared with other women, super-obese women had a significantly higher risk for obstetric (adjusted odds ratio (AOR) 2.42, 95 % CI: 1.77–3.29) and medical (AOR: 2.89, 95 % CI: 2.64–4.11) complications during pregnancy, birth by caesarean section (51.6 %) and admission to special care (HDU/ICU) (6.2 %). The 372 babies born to 365 super-obese women with outcomes known had significantly higher rates of birthweight ≥4500 g (AOR 19.94, 95 % CI: 6.81–58.36), hospital transfer (AOR 3.81, 95 % CI: 1.93–7.55) and admission to Neonatal Intensive Care Unit (NICU) (AOR 1.83, 95 % CI: 1.27–2.65) compared to babies of the comparison group, but not prematurity (10.5 % versus 9.2 %) or perinatal mortality (11.0 (95 % CI: 4.3–28.0) versus 6.6 (95 % CI: 2.6- 16.8) per 1 000 singleton births). Conclusions: Super-obesity in pregnancy in Australia is associated with increased rates of pregnancy and birth complications, and with social disadvantage. There is an urgent need to further address risk factors leading to super-obesity among pregnant women and for maternity services to better address pre-pregnancy and pregnancy care to reduce associated inequalities in perinatal outcomes. Keywords: Super-obesity, Obesity, Perinatal outcomes, Pregnancy, Maternal socio-economic disadvantage, Obstetric complication

Rheumatic heart disease in pregnancy: strategies and lessons learnt implementing a population-based study in Australia

Background The global burden of rheumatic heart disease (RHD) is two-to-four times higher in women, with a heightened risk in pregnancy. In Australia, RHD is found predominantly among Aboriginal and Torres Strait Islander peoples. Methods This paper reviews processes developed to identify pregnant Australian women with RHD during a 2-year population-based study using the Australasian Maternity Outcomes Surveillance System (AMOSS). It evaluates strategies developed to enhance reporting and discusses implications for patient care and public health. Results AMOSS maternity coordinators across 262 Australian sites reported cases. An extended network across cardiac, Aboriginal and primary healthcare strengthened surveillance and awareness. The network notified 495 potential cases, of which 192 were confirmed. Seventy-eight per cent were Aboriginal and/or Torres Strait Islander women, with a prevalence of 22 per 1000 in the Northern Territory. Discussion Effective surveillance was challenged by a lack of diagnostic certainty, incompatible health information systems and varying clinical awareness among health professionals. Optimal outcomes for pregnant women with RHD demand timely diagnosis and access to collaborative care. Conclusion The strategies employed by this study highlight gaps in reporting processes and the opportunity pregnancy provides for diagnosis and re/engagement with health services to support better continuity of care and promote improved outcomes.The authors gratefully acknowledge aid from the Australian National Health and Medical Research Council (NHMRC) project grant #1024206 and NHMRC Postgraduate Scholarship #11332944; University of Technology Sydney Chancellor’s Research Scholarship; and END RHD Centre of Research Excellence, Telethon Kids Institute, University of Western Australia

Maternal super-obesity and perinatal outcomes in Australia: A national population-based cohort study

© 2015 Sullivan et al. Background: Super-obesity is associated with significantly elevated rates of obstetric complications, adverse perinatal outcomes and interventions. The purpose of this study was to determine the prevalence, risk factors, management and perinatal outcomes of super-obese women giving birth in Australia. Methods: A national population-based cohort study. Super-obese pregnant women (body mass index (BMI) >50 kg/m2 or weight >140 kg) who gave birth between January 1 and October 31, 2010 and a comparison cohort were identified using the Australasian Maternity Outcomes Surveillance System (AMOSS). Outcomes included maternal and perinatal morbidity and mortality. Prevalence estimates calculated with 95 % confidence intervals (CIs). Adjusted odds ratios (ORs) were calculated using multivariable logistic regression. Results: 370 super-obese women with a median BMI of 52.8 kg/m2 (range 40.9-79.9 kg/m2) and prevalence of 2.1 per 1 000 women giving birth (95 % CI: 1.96-2.40). Super-obese women were significantly more likely to be public patients (96.2 %), smoke (23.8 %) and be socio-economically disadvantaged (36.2 %). Compared with other women, super-obese women had a significantly higher risk for obstetric (adjusted odds ratio (AOR) 2.42, 95 % CI: 1.77-3.29) and medical (AOR: 2.89, 95 % CI: 2.64-4.11) complications during pregnancy, birth by caesarean section (51.6 %) and admission to special care (HDU/ICU) (6.2 %). The 372 babies born to 365 super-obese women with outcomes known had significantly higher rates of birthweight ≥4500 g (AOR 19.94, 95 % CI: 6.81-58.36), hospital transfer (AOR 3.81, 95 % CI: 1.93-7.55) and admission to Neonatal Intensive Care Unit (NICU) (AOR 1.83, 95 % CI: 1.27-2.65) compared to babies of the comparison group, but not prematurity (10.5 % versus 9.2 %) or perinatal mortality (11.0 (95 % CI: 4.3-28.0) versus 6.6 (95 % CI: 2.6- 16.8) per 1 000 singleton births). Conclusions: Super-obesity in pregnancy in Australia is associated with increased rates of pregnancy and birth complications, and with social disadvantage. There is an urgent need to further address risk factors leading to super-obesity among pregnant women and for maternity services to better address pre-pregnancy and pregnancy care to reduce associated inequalities in perinatal outcomes

Eclampsia in Australia and New Zealand: A prospective population-based study

Background: Eclampsia is a serious consequence of pre-eclampsia. There are lim-ited data from Australia and New Zealand (ANZ) on eclampsia.Aim: To determine the incidence, management and perinatal outcomes of women with eclampsia in ANZ.Materials and Methods: A two-year population-based descriptive study, using the Australasian Maternity Outcomes Surveillance System (AMOSS), carried out in 263 sites in Australia, and all 24 New Zealand maternity units, during a staggered implementation over 2010-2011. Eclampsia was defined as one or more seizures during pregnancy or postpartum (up to 14 days) in any woman with clinical evi-dence of pre-eclampsia.Results: Of 136 women with eclampsia, 111 (83%) were in Australia and 25 (17%) in New Zealand. The estimated incidence of eclampsia was 2.2 (95% confidence inter-val (CI) 1.9-2.7) per 10 000 women giving birth. Aboriginal and Torres Strait Islander women were over-represented in Australia (n = 9; 8.1%). Women with antepartum eclampsia (n = 58, 42.6%) were more likely to have a preterm birth (P = 0.04). Sixty-three (47.4%) women had pre-eclampsia diagnosed prior to their first eclamptic seizure of whom 19 (30.2%) received magnesium sulphate prior to the first seizure. Nearly all women (n = 128; 95.5%) received magnesium sulphate post-seizure. No woman received prophylactic aspirin during pregnancy. Five women had a cer-ebrovascular haemorrhage, and there were five known perinatal deaths.Conclusions: Eclampsia is an uncommon consequence of pre-eclampsia in ANZ. There is scope to reduce the incidence of this condition, associated with often cata-strophic morbidity, through the use of low-dose aspirin and magnesium sulphate in women at higher risk.Funding for AMOSS was through the National Health and Medical Research Council (App ID 510298). In NZ, AMOSS is supported and funded by the Perinatal and Maternal Mortality Review Committee

Simulation of summertime ozone over North America

The concentrations of O3 and its precursors over North America are simulated for three summer months with a three-dimensional, continental-scale photochemical model using meteorological input from the Goddard Institute for Space Studies (GISS) general circulation model (GCM). The model has 4°×5° grid resolution and represents non linear chemistry in urban and industrial plumes with a subgrid nested scheme. Simulated median afternoon O3 concentrations at rural U.S. sites are within 5 ppb of observations in most cases, except in the south central United States where concentrations are overpredicted by 15–20 ppb. The model captures successfully the development of regional high-O3 episodes over the northeastern United States on the back side of weak, warm, stagnant anticyclones. Simulated concentrations of CO and nonmethane hydrocarbons are generally in good agreement with observations, concentrations of NOx are underpredicted by 10–30%, and concentrations of peroxyacylnitrates (PANs) are overpredicted by a factor of 2 to 3. The overprediction of PANs is attributed to flaws in the photochemical mechanism, including excessive production from oxidation of isoprene, and may also reflect an underestimate of PANs deposition. Subgrid nonlinear chemistry as captured by the nested plumes scheme decreases the net O3 production computed in the United States boundary layer by 8% on average

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat