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Paratz ED, Mock N, Marques D, Wilson W, Kushwaha V, Eggleton S, Harries J, da Silva S, Dos Santos da Silva A, Saramento J, de Sousa Maurays J, Flavio R, Horton A, Gutman S, Creati L, Barlis P, Appelbe A, Bayley N. Telemedicine to Timor-Leste: implementing an international cardiac telehealth service during population dislocation, floods and COVID-19. Intern Med J 2022; 52:2076-2085. [PMID: 35319143 PMCID: PMC9111676 DOI: 10.1111/imj.15753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/20/2022] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
Background The East Timor Hearts Fund (ETHF) has provided cardiac services in Timor‐Leste since 2010, conducting three clinics yearly. With international border closures due to the COVID‐19 pandemic, development of collaborative telehealth services was required. Methods Scoping discussions identified major challenges (structural, patient‐related and medical system‐related). At two pilot clinics, patient history, investigation and management were collated. Clinic metrics were compared to an index face‐to‐face clinic in February 2019. Post‐clinic discussions identified areas of success and shortfall in the conduct of the telehealth clinics. Results 23 patients were reviewed at the online telehealth clinics held onsite at Timorese medical facilities. Compared to an index 2019 clinic,there were markedly lower numbers of new referrals (2 vs 190 patients, 8.7% vs 59.4%). Patients seen at the online clinic were predominantly female (17/23, 73.9%) and Dili‐based (18/23, 78.3%) with a mean age of 25.9 ± 7.2 years old. The majority (12/23, 52.2%) had isolated rheumatic mitral valve disease. Investigations including electrocardiography, pathology, echocardiography and 6‐minute walk tests were conducted in select patients. Medication advice was provided for 10 (43.5%) patients. 11 patients (47.8%) were deemed to require urgent intervention. Post‐clinic discussions indicated general satisfaction with telehealth clinics, although frustration at current inability to provide interventional services was highlighted. Conclusion Our pilot telehealth clinics indicate that capacity‐building telemedicine can be rapidly implemented in an emergency setting internationally. Clinic design benefits from careful identification and resolution of challenges to optimise flow. Cardiac patients in Timor‐Leste have a significant burden of disease amenable to intervention. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Elizabeth D Paratz
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Prahran, 3181, VIC, Australia.,Alfred Hospital, 55 Commercial Rd, Prahran, 3181, VIC, Australia.,St Vincent's Hospital Melbourne, 41 Victoria Pde Fitzroy, 3065, VIC, Australia
| | - Nicki Mock
- East Timor Hearts Fund, Melbourne, VIC, Australia
| | | | - Will Wilson
- Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC, 3050
| | - Virag Kushwaha
- Eastern Heart Clinic, Prince of Wales Hospital, Randwick, 2031, NSW, Australia
| | - Simon Eggleton
- Eastern Heart Clinic, Prince of Wales Hospital, Randwick, 2031, NSW, Australia
| | - Jess Harries
- Maluk Timor, Rua Aidak Nurak, Comoro, Dili, Timor-Leste
| | | | | | | | | | | | - Ari Horton
- Monash Children's Hospital, 246 Clayton Rd Clayton, 3168, VIC, Australia
| | - Sarah Gutman
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Prahran, 3181, VIC, Australia.,Alfred Hospital, 55 Commercial Rd, Prahran, 3181, VIC, Australia.,St Vincent's Hospital Melbourne, 41 Victoria Pde Fitzroy, 3065, VIC, Australia
| | - Louise Creati
- St Vincent's Hospital Melbourne, 41 Victoria Pde Fitzroy, 3065, VIC, Australia
| | - Peter Barlis
- St Vincent's Hospital Melbourne, 41 Victoria Pde Fitzroy, 3065, VIC, Australia.,Northern Hospital, 185 Cooper St Epping, 3076, VIC, Australia
| | - Alan Appelbe
- University Hospital Geelong, Bellerine St Geelong, 3220, VIC, Australia
| | - Noel Bayley
- Warrnambool Base Hospital, 25 Ryot St Warrnambool, 3280, VIC, Australia
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Davis K, de Oliveira LN, da Silva Almeida I, Noronha M, Martins J, Dos Santos M, Monteiro A, Brewster D, Horton A, Remenyi B, Francis JR. Morbidity and mortality of rheumatic heart disease and acute rheumatic fever in the inpatient setting in Timor-Leste. J Paediatr Child Health 2021; 57:1391-1396. [PMID: 33825269 DOI: 10.1111/jpc.15476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/25/2021] [Indexed: 11/29/2022]
Abstract
AIM To describe the clinical features, treatment and outcomes of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in children admitted to the national referral hospital in Dili, Timor-Leste. METHODS This prospective study documented cases of ARF and RHD in children aged 14 years and under who were admitted between June 2017 and May 2019. ARF was diagnosed using an adapted version of the 2015 Jones criteria and presumed (rather than proven) exposure to group A Streptococcus. Clinical and echocardiographic findings, comorbidities and discharge outcomes are reported. RESULTS A total of 63 patients were admitted with ARF or RHD; 54 were diagnosed with RHD for the first time. Median age was 11 years (range 3-14); 48% were female. Of those with echocardiograms, 56/58 had RHD, 55/56 (98%) had mitral regurgitation (37/55 (67%) severe), 11/56 (20%) had mitral stenosis and 43/56 (77%) had aortic regurgitation. Left ventricular dysfunction (55%), pulmonary hypertension (64%) and cardiac failure (78%) were common. Four (6%) patients died in hospital, and 30/59 (51%) of surviving patients were lost to follow up. CONCLUSIONS Community echocardiography screening has reported a high prevalence of undetected mild to moderate cases of RHD in Timor-Leste, whereas this hospital study documents mostly severe disease among hospitalised patients with a high case fatality rate and loss to follow up. RHD is a significant health problem in Timor-Leste and improved recognition and diagnosis, as well as effective delivery of treatment and follow-up are imperative.
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Affiliation(s)
- Kimberly Davis
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | | | | | - Mario Noronha
- Department of Paediatrics, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Joao Martins
- Department of Paediatrics, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Milena Dos Santos
- Department of Paediatrics, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Andre Monteiro
- Department of Paediatrics, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - David Brewster
- Department of Paediatrics, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Ari Horton
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,East Timor Hearts Fund, Melbourne, Victoria, Australia
| | - Bo Remenyi
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Joshua R Francis
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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Francis JR, Whalley GA, Kaethner A, Fairhurst H, Hardefeldt H, Reeves B, Auld B, Marangou J, Horton A, Wheaton G, Robertson T, Ryan C, Brown S, Smith G, Dos Santos J, Flavio R, Embaum K, da Graca Noronha M, Lopes Belo S, Madeira Santos C, Georginha Dos Santos M, Cabral J, do Rosario I, Harries J, Francis LA, Draper ADK, James CL, Davis K, Yan J, Mitchell A, da Silva Almeida I, Engelman D, Roberts KV, Ralph AP, Remenyi B. Single-View Echocardiography by Nonexpert Practitioners to Detect Rheumatic Heart Disease: A Prospective Study of Diagnostic Accuracy. Circ Cardiovasc Imaging 2021; 14:e011790. [PMID: 34384239 PMCID: PMC8373443 DOI: 10.1161/circimaging.120.011790] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Echocardiographic screening can detect asymptomatic cases of rheumatic heart disease (RHD), facilitating access to treatment. Barriers to implementation of echocardiographic screening include the requirement for expensive equipment and expert practitioners. We aimed to evaluate the diagnostic accuracy of an abbreviated echocardiographic screening protocol (single parasternal-long-axis view with a sweep of the heart) performed by briefly trained, nonexpert practitioners using handheld ultrasound devices. Methods: Participants aged 5 to 20 years in Timor-Leste and the Northern Territory of Australia had 2 echocardiograms: one performed by an expert echocardiographer using a GE Vivid I or Vivid Q portable ultrasound device (reference test), and one performed by a nonexpert practitioner using a GE Vscan handheld ultrasound device (index test). The accuracy of the index test, compared with the reference test, for identifying cases with definite or borderline RHD was determined. Results: There were 3111 enrolled participants; 2573 had both an index test and reference test. Median age was 12 years (interquartile range, 10–15); 58.2% were female. Proportion with definite or borderline RHD was 5.52% (95% CI, 4.70–6.47); proportion with definite RHD was 3.23% (95% CI, 2.61–3.98). Compared with the reference test, sensitivity of the index test for definite or borderline RHD was 70.4% (95% CI, 62.2–77.8), specificity was 78.1% (95% CI, 76.4–79.8). Conclusions: Nonexpert practitioners can be trained to perform single parasternal-long-axis view with a sweep of the heart echocardiography. However, the specificity and sensitivity are inadequate for echocardiographic screening. Improved training for nonexpert practitioners should be investigated.
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Affiliation(s)
- Joshua R Francis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.).,Maluk Timor, Timor-Leste (J.R.F., J.D.S., R.F., K.E.)
| | - Gillian A Whalley
- Dunedin School of Medicine, University of Otago, New Zealand (G.A.W.)
| | | | - Helen Fairhurst
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.)
| | - Hilary Hardefeldt
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | | | - Benjamin Auld
- Department of Cardiology, Queensland Children's Hospital, Australia (B.A.)
| | - James Marangou
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,NT Cardiac, Australia (A.K., J.M., B.R.)
| | - Ari Horton
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | - Gavin Wheaton
- Department of Cardiology, Women's and Children's Hospital, Australia (G.W., T.R.)
| | - Terry Robertson
- Department of Cardiology, Women's and Children's Hospital, Australia (G.W., T.R.)
| | - Chelsea Ryan
- Maningrida Health Center (C.R., S.B., G.S.), Top End Health Services, Australia
| | - Shannon Brown
- Maningrida Health Center (C.R., S.B., G.S.), Top End Health Services, Australia
| | - Greg Smith
- Maningrida Health Center (C.R., S.B., G.S.), Top End Health Services, Australia
| | | | | | | | - Mario da Graca Noronha
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Sonia Lopes Belo
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Carla Madeira Santos
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Maria Georginha Dos Santos
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Jose Cabral
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Ivonia do Rosario
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | | | - Laura A Francis
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.).,Center for Disease Control (L.A.F., A.D.K.D., C.L.J.), Top End Health Services, Australia
| | - Anthony D K Draper
- Center for Disease Control (L.A.F., A.D.K.D., C.L.J.), Top End Health Services, Australia
| | - Christian L James
- Center for Disease Control (L.A.F., A.D.K.D., C.L.J.), Top End Health Services, Australia
| | - Kimberly Davis
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | - Jennifer Yan
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | | | - Ines da Silva Almeida
- Department of Pediatrics, Hospital Nacional Guido Valadares, Timor-Leste (M.d.G.N., S.L.B., C.M.S., M.G.d.S., J.C., I.d.R., I.d.S.A.)
| | - Daniel Engelman
- Tropical Diseases, Murdoch Children's Research Institute, Australia (D.E.)
| | - Kathryn V Roberts
- Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.)
| | - Anna P Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,Division of Medicine, Royal Darwin Hospital, Australia (A.P.R.)
| | - Bo Remenyi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Australia (J.R.F., H.F., J.M., J.Y., A.P.R., B.R.).,Department of Pediatrics, Royal Darwin Hospital, Australia (J.R.F., H.H., A.H., L.A.F., K.D., J.Y., K.V.R., B.R.).,NT Cardiac, Australia (A.K., J.M., B.R.).,Department of Pediatrics, Cairns Base Hospital, Australia (B.R.)
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4
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Paratz ED, Mock N, Gutman SJ, Horton A, Creati L, Appelbe A, Eggleton S, Kushwaha V, da Silva Almeida IT, Monteiro A, Bayley N. Taking the pulse of Timor-Leste's cardiac needs: a 10-year descriptive time-trend analysis. Intern Med J 2021; 50:838-845. [PMID: 31237730 DOI: 10.1111/imj.14411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Timor-Leste is one of the poorest countries in the world. The East Timor Hearts Fund is a charitable organisation involving Australian cardiologists providing outreach screening and access to cardiac interventions. AIMS To assess ten years of clinical volume, demographics and patient outcomes. Our intention was to identify existing limitations to facilitate planning for further capacity building over the next decade. METHODS The East Timor Hearts Fund database was sectioned into 2-year intervals (2009/2010, 2011/2012, 2013/2014, 2015/2016 and 2017/2018). Demographics and clinical outcomes of patients were compared, with subgroup analysis of adult (>18 years old), paediatric and interventional patients. RESULTS Over 10 years, 2050 patient encounters have occurred; 1119 (54.6%) encounters occurred in 2017/2018; 73.6% of patients were assessed in the capital Dili. Rheumatic and congenital cardiac diseases remain very common (39.1% of adult new patients and 74.2% of paediatric new patients), with 1.4% of new patients exhibiting both pathologies. The number of new patients with rheumatic or congenital heart disease tripled in 2017/2018 compared to 2009/2010 (99 vs 34 patients, P < 0.0001). Paediatric case volume increased over 10-fold over 10 years (288 new patients in 2017/2018 vs 24 in 2009/2010, P < 0.0001), with corresponding increase in proportion of paediatric interventions (59.4% in 2017/2018 vs 25.0% in 2009/2010, P = 0.027). For patients undergoing intervention (n = 87), post-procedural complications and mortality are extremely low (3.4% and 1.1%, respectively), with all eligible patients attending at least one post-procedure appointment. CONCLUSION Demand for cardiac services in Timor-Leste is rising exponentially, with inequitable geographic coverage. Rheumatic and congenital cardiac diseases remain priorities for assessment, and paediatric case volume is increasing. Patients undergoing intervention experience good medical outcomes.
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Affiliation(s)
- Elizabeth D Paratz
- East Timor Hearts Fund, Melbourne, Victoria, Australia.,Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Cardiology Department, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Nicki Mock
- East Timor Hearts Fund, Melbourne, Victoria, Australia
| | - Sarah J Gutman
- East Timor Hearts Fund, Melbourne, Victoria, Australia.,Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Cardiology Department, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Ari Horton
- East Timor Hearts Fund, Melbourne, Victoria, Australia.,Paediatric Cardiology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Louise Creati
- East Timor Hearts Fund, Melbourne, Victoria, Australia.,Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Alan Appelbe
- East Timor Hearts Fund, Melbourne, Victoria, Australia.,Cardiology Department, Geelong Hospital, Geelong, Victoria, Australia
| | - Simon Eggleton
- East Timor Hearts Fund, Melbourne, Victoria, Australia.,Cardiology Department, Eastern Heart Clinic, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Virag Kushwaha
- East Timor Hearts Fund, Melbourne, Victoria, Australia.,Cardiology Department, Eastern Heart Clinic, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Inez T da Silva Almeida
- Internal Medicine, Hospital Nacional Guido Valdares, Dili, Timor-Leste.,Valdares Cardiology, Warrnambool Base Hospital, Warrnambool, Victoria, Australia
| | - Andre Monteiro
- Internal Medicine, Hospital Nacional Guido Valdares, Dili, Timor-Leste.,Valdares Cardiology, Warrnambool Base Hospital, Warrnambool, Victoria, Australia
| | - Noel Bayley
- East Timor Hearts Fund, Melbourne, Victoria, Australia.,Valdares Cardiology, Warrnambool Base Hospital, Warrnambool, Victoria, Australia
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5
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Francis JR, Fairhurst H, Whalley G, Kaethner A, Ralph A, Yan J, Cush J, Wade V, Monteiro A, Remenyi B. The RECARDINA Study protocol: diagnostic utility of ultra-abbreviated echocardiographic protocol for handheld machines used by non-experts to detect rheumatic heart disease. BMJ Open 2020; 10:e037609. [PMID: 32467256 PMCID: PMC7259846 DOI: 10.1136/bmjopen-2020-037609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Rheumatic heart disease (RHD) causes significant morbidity and mortality in young people from disadvantaged populations. Early detection through echocardiography screening can facilitate early access to treatment. Large-scale implementation of screening could be feasible with the combination of inexpensive standalone ultrasound transducers and upskilling non-expert practitioners to perform abbreviated echocardiography. METHODS AND ANALYSIS A prospective cross-sectional study will evaluate an abbreviated echocardiography screening protocol for the detection of latent (asymptomatic) RHD in high-risk populations. The study will evaluate the diagnostic accuracy of health worker conducted single parasternal long axis view with a sweep using handheld devices (SPLASH) (Philips Lumify S4-1 phased array transducer). Each participant will have at least one reference test performed on the same day by an expert echocardiographer. Diagnosis of RHD will be determined by a panel of three experts, using 2012 World Heart Federation criteria. Sensitivity and specificity of the index test will be calculated with 95% CIs, to determine diagnostic accuracy of a screen-and-refer approach to echocardiography screening for RHD. Remote review of SPLASH images obtained by health workers will facilitate evaluation of the sensitivity and specificity of an alternative approach, using external review of health worker obtained SPLASH images to decide onward referral. ETHICS AND DISSEMINATION Ethics approval was obtained from the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research, for the project to be carried out in Timor-Leste (HREC 2019-3399), and in Australia, following review by the Aboriginal Ethics subcommittee (HREC 2019-334). Ethical and technical approval was granted in Timor-Leste, by the Institute National of Health Research Ethics and Technical Committee (1073-MS-INS/GDE/VII/2019). Study results will be disseminated in the communities involved in the study, and through peer-reviewed publications and conference abstracts. TRIAL REGISTRATION NUMBER The Australia New Zealand Clinical Trials Registry (ACTRN12620000122954).
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Affiliation(s)
- Joshua Reginald Francis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Helen Fairhurst
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Gillian Whalley
- Department of Medicine, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
| | | | - Anna Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Jennifer Yan
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - James Cush
- Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Vicki Wade
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Andre Monteiro
- Internal Medicine, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Bo Remenyi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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6
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Fordyce A, Vorias B, Taranto L, Soares A, Watters D, Saunders C. Breast disease in Timor-Leste. ANZ J Surg 2020; 90:1920-1924. [PMID: 32062871 DOI: 10.1111/ans.15720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/09/2020] [Accepted: 01/12/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgically treatable conditions are well documented in high-income countries. There is a gap in epidemiological understanding of breast pathology in many developing countries, Timor-Leste among them. This study was conducted to determine the burden of breast disease and to inform public health measures to address early detection, diagnosis and management. METHODS A retrospective quantitative case-control study was conducted at Guido Valadares National Hospital in Dili. Patients were included if they attended surgical outpatients or had a pathology specimen recorded between 1 September 2016 and 1 September 2017. RESULTS There were 444 female patients with a clinical diagnosis of breast disease over the 12-month period. The average age was 33.7 years. There were 188 (42.3% of total sample) cases of fibroadenoma and 122 (27.4% of total sample) diagnoses consistent with non-specific lumps. Of the 116 female patients presenting to Guido Valadares National Hospital who had a biopsy, 62.6% were malignant or hyperplastic in nature, and 86% of those with a malignant biopsy had clinically locally advanced disease. CONCLUSION Breast conditions including cancer in Timor-Leste are relatively common and occur in young women in the prime of their lives (37 years of age). Developing a national cancer registry and funding directed towards improving early presentation and good clinical care of breast cancer patients will be critical for reducing early morbidity and mortality and improving other patient outcomes including income loss, gender health inequality and the intergenerational effects of early parental death.
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Affiliation(s)
- Andrew Fordyce
- Department of General Surgery, Alfred Health, Melbourne, Victoria, Australia.,Global Health Division, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Blake Vorias
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Lucas Taranto
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Alito Soares
- Department of Surgery, Guido Valadares National Hospital, Dili, Timor-Leste
| | - David Watters
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Christobel Saunders
- School of Surgery and Pathology, The University of Western Australia, Perth, Western Australia, Australia.,Department of Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Surgery, St John of God Hospital, Perth, Western Australia, Australia
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7
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Adult and Paediatric Cardiac Intervention in Timor-Leste: Disease Burden, Demographics and Clinical Outcomes. Heart Lung Circ 2019; 29:1112-1121. [PMID: 31831263 DOI: 10.1016/j.hlc.2019.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The East Timor Hearts Fund (ETHF) is a charitable organisation of Australian cardiologists providing outreach screening in Timor-Leste. For patients requiring intervention, ETHF arranges logistics, procedures, and postoperative care. The aim of this project is to evaluate outcomes of patients requiring intervention. METHODS The ETHF database of all patients was utilised to identify patients with disease warranting surgical or percutaneous intervention. Both patients who underwent intervention and those who did not proceed to intervention were included in this study. Patients who had intervention arranged by other organisations but have then had follow-up with ETHF were also included. Overall demographics and pre and postoperative factors were assessed, with sub-group analysis of adult and paediatric patients to identify any differences in care. RESULTS Of 221 patients requiring intervention, 101 patients underwent intervention, receiving 22 different operations or procedures. Patients were predominantly young (median age 17.5 years) and female (64.7%), with rheumatic heart disease (63.8%). Twenty-four (24) (33.3%) women aged 15-45 years old with cardiac disease warranting intervention were documented as pregnant or breastfeeding at time of clinic assessment. Of patients who did not proceed to intervention, adults were more likely to be lost to follow-up (42.4% vs 18.5%) while paediatric patients were more likely to experience progression of disease (18.5% vs 7.5%, p=0.005). Median waitlist time was 5 months, with no significant difference between adults and children, correlating with a preoperative mortality rate of 5.4%. For patients who underwent intervention, post-procedure mortality was extremely low (0.9%) and attendance of at least one post-procedure review was excellent (99.0%). Eleven (11) (10.9%) patients have required repeat intervention, with no difference in rates between adult and paediatric patients. Length of follow-up extends up to 20 years for some patients. CONCLUSION The Timor-Leste interventional cohort was predominantly a young female population with rheumatic and congenital cardiac disease. There were also high rates of pregnancy amongst female patients with severe cardiac disease. Delayed access to intervention may result in preoperative adverse events and mortality, and is a key target for improvement. Patients who undergo intervention have very low post-procedural mortality, good adherence to early medical follow-up and good long-term outcomes.
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Remenyi B, Davis K, Draper A, Bayley N, Paratz E, Reeves B, Appelbe A, Wheaton G, da Silva Almeida IT, Dos Santos J, Carapetis J, Francis JR. Single Parasternal-Long-Axis-View-Sweep Screening Echocardiographic Protocol to Detect Rheumatic Heart Disease: A Prospective Study of Diagnostic Accuracy. Heart Lung Circ 2019; 29:859-866. [PMID: 31320258 DOI: 10.1016/j.hlc.2019.02.196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/28/2019] [Accepted: 02/05/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Echocardiographic screening in school-aged children can detect rheumatic heart disease (RHD) prior to the manifestation of symptoms of heart failure. The challenge is making this practical and affordable on a global scale. This study aims to evaluate the diagnostic utility of an ultra-abbreviated echocardiographic screening protocol involving a single parasternal-long-axis-view-sweep of the heart (SPLASH) in two dimensional (2D) and colour Doppler imaging (index test). METHODS This prospective study of diagnostic accuracy compared the diagnostic utility of the index screening test with a comprehensive reference test (standard echocardiographic screening protocols) as per World Heart Federation (WHF) echocardiographic criteria. School students in Timor-Leste aged 5-20 years were enrolled. Both index and reference test images were acquired by cardiologists on Vivid I or Q machines (GE Healthcare, Marlborough, MA, USA). RESULTS A total of 1,365 participants were screened; median age was 11 years. The estimated prevalence of definite and borderline RHD was 35.2 per 1,000. Congenital heart disease was identified in 11 children (0.8%) with two needing cardiac surgery. Abnormal SPLASH views were found in 109/1365 (7.99%). No cases of RHD or significant congenital heart disease were missed. Sensitivity and specificity of the abbreviated protocol for detecting RHD were 1.0 and 0.95 respectively. CONCLUSIONS A simplified echocardiography screening protocol using SPLASH is highly sensitive and specific and could significantly improve the efficiency of RHD screening. It has the potential to expedite training of health workers whilst protecting the modesty of students.
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Affiliation(s)
- Boglarka Remenyi
- Royal Darwin Hospital, Darwin, NT, Australia; Menzies School of Health Research, Darwin, NT, Australia.
| | - Kimberly Davis
- Royal Darwin Hospital, Darwin, NT, Australia; Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Anthony Draper
- Centre for Disease Control, Darwin, Darwin, NT, Australia
| | | | | | | | | | - Gavin Wheaton
- Women's and Children's Hospital, Adelaide, SA, Australia
| | | | | | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, Perth, WA, Australia; Perth Children's Hospital, Perth, WA, Australia
| | - Joshua R Francis
- Royal Darwin Hospital, Darwin, NT, Australia; Menzies School of Health Research, Darwin, NT, Australia
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Abstract
PURPOSE OF REVIEW Chronic breathlessness is common in patients with advanced illness who require palliative care. Achieving good symptom control can be challenging. More people with advanced illness live in low and middle income than in high-income countries, but they are much less likely to receive palliative care. Most of the emerging evidence for the palliative management of chronic breathlessness is from high-income countries. This review explores the context of chronic breathlessness in low-income settings, how evidence for control of chronic breathlessness might relate to these settings and where further work should be focused. RECENT FINDINGS Systems for control of noncommunicable diseases (NCDs) in these low-income contexts are poorly developed and health services are often overwhelmed with high levels both of NCD and communicable disease. Multidisciplinary and holistic approaches to disease management are often lacking in these settings. Developing an integrated primary care approach to NCD management is increasingly recognized as a key strategy and this should include palliative care. Most evidence-based approaches to the control of chronic breathlessness could be adapted for use in these contexts SUMMARY: Hand held fans, breathing techniques, graded exercise and use of low-dose morphine can all be used in low-income settings particularly in the context of holistic care. Research is needed into the most effective ways of implementing such interventions and palliative care needs to be promoted as a fundamental aspect of NCD management.
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Davis K, Remenyi B, Draper ADK, Dos Santos J, Bayley N, Paratz E, Reeves B, Appelbe A, Cochrane A, Johnson TD, Korte LM, Do Rosario IM, Da Silva Almeida IT, Roberts KV, Carapetis JR, Francis JR. Rheumatic heart disease in Timor‐Leste school students: an echocardiography‐based prevalence study. Med J Aust 2018; 208:303-307. [DOI: 10.5694/mja17.00666] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Kimberly Davis
- Royal Darwin Hospital, Darwin, NT
- Hospital Nacional Guido Valadares, Dili, Timor‐Leste
| | | | - Anthony DK Draper
- Centre for Disease Control, Northern Territory Department of Health, Darwin, NT
| | | | | | | | | | - Alan Appelbe
- Geelong Cardiology Group, Barwon Health, Geelong, VIC
| | | | | | - Laura M Korte
- Paediatric WA Country Health Service – Kimberley, Broome, WA
| | | | | | | | | | - Joshua R Francis
- Royal Darwin Hospital, Darwin, NT
- Global and Tropical Health Division Menzies School of Health Research, Darwin, NT
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