Chronic condition risk factor change over time in a remote Indigenous community

INTRODUCTION

This study sought to determine change in chronic condition risk factors in a remote Indigenous community following a 3-year period of community-led health promotion initiatives.

METHODS

Data were compared between two cross-sectional surveys of Indigenous Australian community residents before and after health promotion activities, and longitudinal analysis of participants present at both surveys using multilevel mixed-effects regression.

RESULTS

At baseline, 294 (53% women; mean age 35 years) participated and 218 attended the second survey (56% women, mean age 40 years), and 87 attended both. Body composition, blood pressure and urinary albumin-to-creatinine ratio remained stable between baseline and follow-up. After adjusting for age and sex, haemoglobin A1c significantly increased (from 57 to 63 mmol/mol (7.5% to 8.1%), p=0.021) for those with diabetes. Increases were also observed for total cholesterol (from 4.4 to 4.6 mmol/L, p=0.006) and triglycerides (from 1.5 to 1.6 mmol/L, p=0.019), and high-density lipoprotein cholesterol levels improved (from 0.98 to 1.02 mmol/L, p=0.018). Self-reported smoking prevalence was high but stable between baseline (57%) and follow-up (56%). Similar results were observed in the longitudinal analysis to the cross-sectional survey comparison.

CONCLUSION

Community-led health promotion initiatives may have had some benefits on chronic condition risk factors, including stabilisation of body composition, in this remote Indigenous community. Given that less favourable trends were observed for diabetes and total cholesterol over a short time period and smoking prevalence remained high, policy initiatives that address social and economic disadvantage are needed alongside community-led health promotion initiatives.

Factors influencing food choice in an Australian Aboriginal community

We explored with Aboriginal adults living in a remote Australian community the social context of food choice and factors perceived to shape food choice. An ethnographic approach of prolonged community engagement over 3 years was augmented by interviews. Our findings revealed that knowledge, health, and resources supporting food choice were considered "out of balance," and this imbalance was seen to manifest in a Western-imposed diet lacking variety and overrelying on familiar staples. Participants felt ill-equipped to emulate the traditional pattern of knowledge transfer through passing food-related wisdom to younger generations. The traditional food system was considered key to providing the framework for learning about the contemporary food environment. Practitioners seeking to improve diet and health outcomes for this population should attend to past and present contexts of food in nutrition education, support the educative role of caregivers, address the high cost of food, and support access to traditional foods.

Integrating an ecological approach into an Aboriginal community-based chronic disease prevention program: a longitudinal process evaluation

Background

Public health promotes an ecological approach to chronic disease prevention, however, little research has been conducted to assess the integration of an ecological approach in community-based prevention programs. This study sought to contribute to the evidence base by assessing the extent to which an ecological approach was integrated into an Aboriginal community-based cardiovascular disease (CVD) and type 2 diabetes prevention program, across three-intervention years.

Methods

Activity implementation forms were completed by interview with implementers and participant observation across three intervention years. A standardised ecological coding procedure was applied to assess participant recruitment settings, intervention targets, intervention strategy types, extent of ecologicalness and organisational partnering. Inter-rater reliability for two coders was assessed at Kappa = 0.76 (p < .0.001), 95% CI (0.58, 0.94).

Results

215 activities were implemented across three intervention years by the health program (HP) with some activities implemented in multiple years. Participants were recruited most frequently through organisational settings in years 1 and 2, and organisational and community settings in year 3. The most commonly utilised intervention targets were the individual (IND) as a direct target, and interpersonal (INT) and organisational (ORG) environments as indirect targets; policy (POL), and community (COM) were targeted least. Direct (HP→ IND) and indirect intervention strategies (i.e., HP→ INT→ IND, HP→ POL → IND) were used most often; networking strategies, which link at least two targets (i.e., HP→[ORG-ORG]→IND), were used the least. The program did not become more ecological over time.

Conclusions

The quantity of activities with IND, INT and ORG targets and the proportion of participants recruited through informal cultural networking demonstrate community commitment to prevention. Integration of an ecological approach would have been facilitated by greater inter-organisational collaboration and centralised planning. The upfront time required for community stakeholders to develop their capacity to mobilise around chronic disease is at odds with short-term funding cycles that emphasise organisational accountability.

Pulmonary hypertension: a review of the aetiology, pathophysiology and management

Pulmonary hypertension (PH) is defined as a systolic pulmonary artery pressure (PAP) above 30 mmHg and a mean PAP above 25 mmHg. Pulmonary hypertensive diseases (PHDs) encompass a myriad of conditions that cause pulmonary hypertension (PH), hence the Evian Classification was developed for the categorization of the various causes. Pulmonary hypertensive diseases are complex conditions that are difficult to treat and in the case of primary pulmonary hypertension, there is no known cure. Dyspnoea on exertion is the main symptom. This usually worsens as the disease progresses and can lead to syncope as a result of right ventricular failure. Prostacyclin has been the mainstay of treatment for decades, but several new drugs and alternate methods of treatment are currently available.

Acute renal failure post coronary artery bypass grafting at the University Hospital of the West Indies

OBJECTIVES

The purpose of the study was to determine the period prevalence of acute renal failure (ARF) after coronary bypass surgery (CABG) at the University Hospital of the West Indies and to identify risk factors.

METHOD

A retrospective analysis of patients who underwent CABG during the period 1994-2004 was done. Data collected included; age, gender, weight, the presence of hypertension (HTN), diabetes mellitus (DM), hypercholesterolaemia, previous myocardial infarction (MI), blood pressure on admission, urea and creatinine one year prior to surgery, on admission for surgery and post-surgery, duration of intra-operative hypotension, duration of cardiopulmonary bypass, perfusion pressure and the perioperative medications.

RESULTS

The case notes of 62 patients (68.9%) were obtained for analysis. There were 47 (75.8%) males and 15 females (24.2%)--a 3:1 ratio. The prevalence of HTN and DM in the study sample was 78% and 72% respectively, hypercholesterolaemia was 31% and a previous MI was 29%. There were no differences based on gender. Post CABG complications were: persistent postoperative hypotension (6.8%), congestive cardiac failure (CCF) (6.8%), arrhythmia (6.8%), sepsis (6.8%), lower respiratory tract infection (LRTI) and pleural effusion (5.1%), heart block (3.4%), pulmonary embolism (1.7%), cellulitis and haematoma formation were 1.7%. Three patients had increases in postoperative creatinine values > 89 micromol/L over the postoperative value resulting in a prevalence of ARF of 5%. One of the three patients died and none received dialysis. There were no statistical difference in pre-operative clinical and biochemical characteristics based on the presence or absence of ARE. The presence of diabetes and increased length of stay were significant predictors of increasing postoperative creatinine values adjusting for pre-operative creatinine values. In addition, the presence of diabetes mellitus and male gender were significant predictors of increasing postoperative urea values.

CONCLUSION

DM is a significant risk factor for the development of ARF post CABG.

Paediatric day surgery: revisiting the University Hospital of the West Indies experience

Day surgery is cheaper and allows for less time delay. In developing countries with limited health budgets, these factors lead to higher patient turnover and shortened waiting lists. The decreased psychological trauma for both parents and children is significant. Paediatric day surgery (PDS) has been done at the University Hospital of the West Indies (UHWI) for over 40 years. A total of 975 paediatric general surgical (PGS) procedures were performed on 963 patients at the UHWI during the four-year period, January 2001 to December 2004. Paediatric day surgery numbered 727 (74.6%). Males outnumbered females 2:1, the age range was 2 weeks to 15 years, with an average age of 4 years. Ninety-seven (13.3%) of these patients were less than six months old, including eight neonates. One hundred and forty-five (20%) had more than one surgical procedure. Most children, 314 (43.2%) had inguinal hernia repair. Umbilical/supra-umbilical/epigastric herniorrhaphy (20.1%) was the next most frequently performed procedure, followed by circumcision (13.3%) and orchidopexy (5.9%). Ninety per cent of these patients were discharged home within 2-4 hours after surgery. Unplanned admissions were 2.1% of the cases. These were due to age, unplanned extensive surgical procedure, drug reaction and fever There was no mortality in this study population. This review showed that the number of PDS has increased from 60% in 1984 to 75%. These procedures were performed safely with a low complication rate. Further expansion of the service is recommended.

Open splenectomy in Jamaican children with sickle cell disease

A total of 110 patients with sickle cell disease who had open splenectomy at the University Hospital of the West Indies over a 10-year period are reviewed Patients with homozygous sickle cell disease numbered 94, S beta0 and S beta+ thalassaemias (11 and 4 respectively) and one patient with SC disease. Postoperative acute chest syndrome was the most common complication (9 of 110). There were no life threatening emergencies and no mortalities. Eleven patients received preoperative blood transfusion and operative times were short averaging 60 minutes among the 110 patients. Open splenectomy remains the gold standard for patients with sickle cell disease requiring splenectomy.

Anaesthesia for operative deliveries at the University Hospital of the West Indies: a change of practice

There has been an increasing trend worldwide to use regional anaesthesia for operative deliveries. The Confidential Enquiry into Maternal Deaths in the United Kingdom has demonstrated a steady decline in the anaesthesia-related deaths since the introduction of regional anaesthesia. There are lower morbidity profiles in mothers delivering under regional anaesthesia as well as better infant Apgar scores. In 1997, a decision was taken to have at least 60% of all elective Caesarean sections done at the University Hospital of the West Indies (UHWI) performed under spinal anaesthesia. This is a review of the anaesthetic technique for Caesarean sections at the UHWI since 1996. The Deliveries and Anaesthetic Books on the labour ward were reviewed and the type of anaesthesia for elective and emergency Caesarean sections recorded for the period January 1996 to December 2001. At the beginning of the period under study, more than 90% of the Caesarean sections were being done under general anaesthesia. By the middle of 1998, spinal anaesthesia was more commonly employed than general anaesthesia for Caesarean sections and by December 2001, more than eight out of every ten Caesarean sections were being done under spinal anaesthesia. The main reasons for the successful change of practice were that it was consultant-led, there was good communication between relevant departments, the junior staff were properly trained, there was a consistent supply of appropriate drugs and there was a high level of patient satisfaction.

Vomiting post tonsillectomy at the University Hospital of the West Indies

A three-year observational study of patients undergoing tonsillectomy at the University Hospital of the West Indies was conducted to determine the incidence of postoperative vomiting. Data were collected to assess possible risk factors for vomiting as well as possible alleviating agents. Two hundred and fifty-two patients were included in the study and a thirteen per cent incidence of postoperative vomiting was found. This is significantly less than that quoted in other studies (40-73%). Results also showed that steroids significantly reduced the incidence of postoperative vomiting in the study population. Muscle relaxants reversal agents and antibiotics particularly co-trimoxazole and ceftriaxone significantly increased its incidence. Usual antiemetic agents including dimenhydrinate (gravol) and promethazine (phenergan), as well as drugs known to possess antiemetic properties such as midazolam and propofol, lacked any significant protective effect against emesis. Opioid analgesia, inhalational induction and blood loss of greater than 10% of estimated blood volume appeared to increase emesis but failed to achieve statistical significance.

Initial experience with beating-heart single valve replacement surgery at the University Hospital of the West Indies, Kingston, Jamaica

The objective of this study was to examine the consequences of performing single cardiac valve replacement procedures utilizing a beating-heart technique on typical patients presenting to the cardiothoracic surgery service for aortic or mitral valve replacement. Beating heart aortic (4) or mitral valve (1) replacement was performed on patients from July 2000 to November 2002. A stratified sample of five patients who underwent standard arrested-heart single valve replacement procedures between April 1997 and November 2002 was selected for retrospective comparison with the beating-heart group. Operative and post-operative variables were compared between the two groups of patients and subjected to statistical analysis. There was no statistical difference between the two groups with respect to age, pre- or post-operative New York Heart Association (NYHA) scores, cardiopulmonary bypass time, aortic cross-clamp time, intra-operative blood transfusion, or post-operative hospital stay. Post-operatively, in the beating heart group, ventilation time, mediastinal blood loss and requirements for inotropic drugs were significantly reduced (p = 0.0054), p = 0.0019 and 0 = 0.02 respectively) compared to the arrested-heart group. Single cardiac valve replacement surgery utilizing a beating heart technique may offer benefits to patients over traditional arrested-heart surgery. Post-operative blood loss, inotrope requirements and ventilation times are significantly reduced, possibly resulting in better recovery and potentially fewer complications in the post-operative period. There may be cost benefits, important in the context of healthcare delivery in developing nations. These early results suggest the need for a regional prospective randomized trial to compare beating-heart single valve replacement surgery with traditional techniques.

Thymic surgery in Jamaica 1992-2000

The treatment for thymic tumours and/or myaesthenia gravis (MG) includes thymectomy. Controversy exists as to the optimal timing and operative approach to thymectomy. At the University Hospital of the West Indies, Kingston, Jamaica, the results of thymic surgery during the period 1992 to 2000 were studied retrospectively. There were 26 patients operated on, 17 females and nine males. Twenty-three underwent thymectomy to treat MG, and three to remove a thymoma. The average age for females was 30.7 years, and 25.1 years for males. Average duration of symptoms prior to surgery was 16 months (all patients), and the interval between diagnosis and referral averaged 2.6 months. All patients underwent thymectomy via median sternotomy with a cervical extension of the incision if required. A policy of phrenic nerve preservation, even if residual tumour was left behind, was followed. Patients with thymomas were given post-operative radiotherapy. Chemotherapy was not given to any patient. The medium and long term results of thymic surgery in a developing country are presented. The results are within international norms, although the small patient population makes statistical analysis difficult. There appears to be no need to change current practice, despite the reported efficacy of less invasive approaches to thymic surgery.

Preoperative starvation and pulmonary aspiration. New perspectives and guidelines

The fear of aspiration of gastric contents and its life-threatening consequences in patients(aspiration pneumonitis and respiratory failure), has caused many medical practitioners, particularly anaesthetists, to rigidly follow conservative (i.e. prolonged) preoperative fasting standards. This is the nil per os (NPO) order for clear fluids/liquids and solids overnight or six to eight hours preceding the induction of anaesthesia. This practice neither takes into account the differences in the rate of gastric emptying for solid food (which may exceed six hours) and clear liquids (which is one to two hours), nor the differences in scheduled times of surgery. Long-term prospective studies and retrospective reviews have shown that the incidence of significant clinical aspiration is low: 1.4-6.0 per 100,00 anaesthetics for elective general surgery. Risk factors for pulmonary aspiration include: a high American Society of Anaesthesiologists (ASA) physical status score; emergency surgery; difficult airway management; increased gastric volume and acidity; increased intra-abdominal pressure; gastro-oesophageal reflux; oesophageal disease; head injury with impaired consciousness and extremes of age. Experimental studies and reviews have consistently shown the safety of clear liquid ingestion up to two hours before induction of anaesthesia in healthy patients without risk factors, and the fact that a longer fluid fast does not necessarily offer any added protection against pulmonary aspiration. The conservative pre-operative fasting standard causes discomfort and in some cases, suffering of patients and is therefore unnecessary for patients without risk factor(s). Anecdotal reports at the University Hospital of the West Indies (UHWI) have shown that application of the liberalized guidelines for preoperative fasting and fluid intake has not resulted in increased pulmonary aspiration, morbidity or mortality. Instead it has resulted in decreased irritability, anxiety, thirst and hunger in the peri-operative period. Patients, especially children are more comfortable and the perioperative period is better tolerated. It is therefore time that all medical personnel adopt the liberalized guidelines.

Classification and surgical management of orbital fractures: experience with 111 orbital reconstructions

Orbital skeletal injuries are frequently associated with other significant injuries and require a substantial surgical effort to correct. The use of a unified classification of orbital injury may better predict the surgical effort required to correct such injuries and help with future comparisons of results. In an attempt to summarize the principles of reconstruction of the orbital skeleton following trauma and introduce a unified classification system for orbital injuries, a retrospective review of all consecutive orbital reconstructions in a tertiary care teaching hospital was conducted. The nasoethmoidal region was involved in 32%, the zygomatic complex in 50%, and the frontal region in 28% of orbital fractures. Of the orbital walls, four walls were involved in 5%, three walls in 17%, two walls in 30%, and one wall in 53%. Associated ocular and neurologic injury was encountered in 33% and 57% of patients, respectively. Regions of fixation ranged from one to eight. Bone grafts were used in 20% and titanium mesh in 34% of the orbits. In general, the authors recommend an aggressive approach to orbital injuries, addressing all associated injuries simultaneously.

Severe neurological complications post-open heart surgery. The Jamaican experience

During the period January 1994 to December 1999, a total of 395 patients--adults and children--underwent various types of open heart surgical (OHS) procedures. The age range of these patients was 10 days to 77 years. Most (43.5%) of these patients underwent valve replacement--first time and 'redo'--as a result of rheumatic heart disease of varying duration and severity. The other large group was the complex congenital heart abnormalities (16%), followed by the group that underwent repair of atrial septal defect (13%), coronary artery bypass graft (13%) and repair of ventricular septal defect (12%). Open valve repair (2%) and excision of atrial myxoma (0.5%) were uncommon OHS procedures. Nine patients (2.3%) developed severe neurological complications (NCs) post-OHS. These included: a short period (< 48 hours) of irritability and fluctuating consciousness level; seizure activity associated with hemisparesis and/or blindness; severe encephalopathy and vegetative state. Four patients showed complete recovery, but one died as a result of complications of the anti-seizure medication. Of the other five, four died as a result of the NCs, and one was discharged in a vegetative state. Such severe neurological complications after an otherwise successful cardiac surgery represent a devastating outcome for patients and their families, and the social and economic impacts are enormous. Several risk factors were identified. The main ones being mitral valve replacement (MVR), especially 'redo' surgery, female gender, age over 60 years, high New York Heart Association functional class and post-operative hypotension. However, the true incidence of NCs (gross and subtle) in the study group cannot be ascertained. A detailed, structured neurological and neuropsychiatric assessment, both pre- and post-operatively, is therefore needed to document the true incidence of this complication. There is also the need for public education, especially for those with valvular disease, in order to encourage changes in attitude and behaviour towards continued follow-up care and valve surgery, both first time and 'redo'.

Thyroid surgery: a comparison of outcomes between experts and surgeons in training

OBJECTIVES

Our objective was to compare the results of thyroid surgery performed by residents in a large metropolitan public hospital (MPH) with those performed by faculty in a large private hospital (PH) setting.

METHODS

All records of thyroid surgery performed by otolaryngologists for the period between 1986 and 1998 were reviewed. Inclusion criteria were adequacy of data and follow-up. Ninety-two thyroid procedures performed by residents in an MPH were compared with 181 thyroid operations in a PH setting performed by the faculty of these residents for differences in accuracy of diagnostic studies, operative parameters, and complication rates.

RESULTS

The demographic distribution in both groups was similar. Presenting symptoms were twice as frequent in the MPH group (45% vs 22%). More total thyroidectomies were performed in the PH group (49% vs 32%). Blood loss, operative time, and hospitalization days were similar in both groups. Preoperative fine needle aspiration and intraoperative frozen section results showed sensitivities and specificities that were comparable. No permanent vocal cord paralysis was observed in either group. Permanent hypocalcemia was more frequent in the PH group (8.8%:PH vs 5.1%:MPH).

CONCLUSIONS

The results of thyroid surgery performed by residents in training in an Otolaryngology-Head & Neck Surgery program in an MPH, measured by rates of complications, length of hospitalization, and duration of surgery, are similar to those of faculty at a PH setting in groups of patients with very similar characteristics.

Methodological issues in evaluating HIV prevention community planning

To be effective, HIV prevention programs should be planned in partnership with affected communities and should be built on a solid scientific foundation. In 1994, the Centers for Disease Control and Prevention (CDC) and its prevention partners implemented HIV prevention community planning to achieve primarily these two objectives. In order to manage the community planning process effectively, extensive evaluation activities were employed at both the grantee and national level. This paper describes the first year evaluation goals and methods in detail. Throughout, reasons for collecting specific types of information and for using particular methodologies are highlighted.