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

Postoperative Delirium in the Colorectal Surgical Population

Delirium is the clinical diagnosis of an acute confusional state, characterised by impaired cognition, fluctuating levels of consciousness, altered psychomotor activity, and a disturbed sleep-wake cycle. Delirium is recognised as a common and serious problem for older hospitalised patients and is associated with longer, more costly hospitalisations, increased rates of nursing home placement, functional decline, rehabilitation needs, home healthcare, and caregiver burden. Surgery is a known risk factor for the development of delirium and with an aging, sicker population undergoing surgery, postoperative delirium (POD) is emerging as a frequent complication. POD is a potentially preventable and reversible condition, therefore early detection and identification of factors contributing to the development of POD, is one of the most important current issues in surgical nursing care. Because POD is not a naturally occurring illness, its study must occur within the context of specific populations. POD has not previously been investigated in the colorectal surgical population. This study investigated the prevalence and incidence of POD in a colorectal surgical sample (n=118) using a validated delirium diagnostic instrument applied daily for three days postoperatively. Numerous other data were collected during the study period in order to characterise the sample and identify predictors for POD development in colorectal surgical patients. The sample was about half women (54.2%) with a mean age of 71.81 years. Most participants (64.4%) were married or in de-facto relationships. Many of the participants had other conditions. Most frequently, these were hypertension (56.8%), arthritis (38.1%) and hypercholesterolemia (36.4%). One in five participants (21.1%) had five or more concomitant conditions. In addition to these concomitant conditions, many participants had impaired vision (48.3%). Few participants were current smokers (14.4%), but one in five (20.3%) exceeded daily alcohol intake guidelines. These participants were assessed once daily for three days. The overall prevalence of POD was 34.7% with the incidence of POD within the first 24 hours 21.2%. Throughout the study, new cases of POD continued to be identified each day with a small number of participants (6.8%) having POD on all three postoperative days. Whilst the number of new cases of POD decreased each day, the daily POD incidence did not markedly decline throughout the study. Several pre-existing characteristics were found to differentiate those who developed POD from those who did not. For POD that developed in the first 24 hours (POD One), these characteristics were being unmarried and, hospitalized and given intravenous (IV) hydration on the day prior to surgery and for POD at any time in the first 72 hours (POD Ever) they were older age, being male and requiring a HDU admission postoperatively