Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Doctor James Doran
1. Acknowledgement
• I would like to acknowledge and pay my respects to the
traditional owners of this land we are meeting upon today.
2. Rheumatic Heart Valve Surgical
Outcomes in the Top End of the
Northern Territory, Australia
1997-2016
D R J A M E S D O R A N
M B , B . C H , B A O ( N U I ) , L R C P I & L R C S I , B . S C .
F R A C G P , C E R T C L I N I C A L U LT R A S O U N D .
M S M A I D A S T E WA R T
A B O R I G I N A L H E A LT H P R A C T I T I O N E R
A / P R O F E S S O R N A D A R A J A H K A N G A H A R A N
4. Outline
• Integrated Primary Care Cardiology Clinic Model
• Development of a clinical register to tract our patients
progress within an ACCHS.
• Proposed Pilot study in the training in the use of focused
cardiac ultrasound by primary care medical staff within an
Aboriginal Community Controlled Health Service.
5. Introduction
• Rheumatic Heart Disease (RHD) is the leading cause of heart valve
dysfunction in the Northern Territory (NT) (Carapetis, Kilburn et al.
1997).
• Precursor Acute Rheumatic Fever (ARF), 194 cases per 100,000 in
the NT (Lawrence, Carapetis et al. 2013).
• 61% develop RHD within 10 years of initial ARF diagnosis
(Lawrence, Carapetis et al. 2013).
• Mild RHD at diagnosis, at 1, 5 and 10 years, 0.3%, 2.4% and 5.1%
proceeded to surgery (Cannon, Roberts et al. 2017).
• Moderate RHD at diagnosis, at 1, 5 and 10 years, 1.2%, 9.3% and
15.7% proceeded to surgery (Cannon, Roberts et al. 2017).
• Severe RHD at diagnosis at 1, 5 and 10 years, 41.6%, 59.7% and
62.7% had proceeded to surgery (Cannon, Roberts et al. 2017).
6. Aims
•Develop a RHD Clinical Register containing preoperative,
intraoperative, post operative, short and long-term outcome
data between 1997 and 2016 with continued prospective
analysis.
•Describe the progression of disease in our RHD surgical
cohort from date of diagnosis, looking in detail at first and
latest rheumatic heart valve surgical procedures.
•Determine the impact of preoperative, intraoperative and
post-operative variables on short and long term outcomes
and their relationship to morbidity and mortality.
7. Methods
• Ethics approval was obtained from the Human Research Ethics
Committee of the NT department of Health and Menzies School of
Health Research. HREC reference number: 2016-2556.
• Designed and build a secure RHD clinical register.
• Retrospective collection of data on 376 patients who had their first
valve surgery between 1997 and 2016, using clinical information
systems in both private and public sectors of the NT.
• 236 patients have been comprehensively analysed. Dates of RHD
diagnosis, episodes of ARF, surgical dates and death recorded for
the remaining 140 of which analysis is ongoing.
8. Methods
• All data analysis was carried out on STATA (version 14.2
STATA Corp LP, Texas, USA).
• Currently descriptive data analysis is ongoing, survival
analysis data to follow.
14. 30 Day Post-Operative Outcome
First Surgery
n = 236
30 day return to theatre
after first surgery
n=17
Last Surgery
n=64
Perioperative
Mortality
4 (1.9%) 1 (6.2%) 4 (6.8%)
Embolic Stroke 1 (0.5%) 0 1 (1.7%)
Endocarditis
1 (0.5%) 0 6 (9.7%)
A fib 70 (33.3%) 32 (51.6%)
15. Long Term Complications
Long Term Complications
TIA 13 (6%) Pulmonary embolism 2 (0.9%)
Embolic Stroke 28 (12.1%) Valve Thrombosis 17 (7.3%)
Haemorrhagic Stroke 2 (0.88%) Subdural Haematoma
on warfarin
5 (2.6%)
Sternal Wound
Infection
15 (6.6%) PPM 12 (5.1%)
Infective Endocarditis 29 (12.6%) ICD insertion 7 (3.0%)
16. Latest Echocardiography
Last Echocardiography
Mitral regurgitation Moderate
Moderate to Severe
Severe
23 (16.4%)
1 (0.7%)
4 (2.9%)
Mitral Stenosis
Mean Gradient 7.1mmHg
Mean Mitral Valve area 1.7cm2
Moderate
Moderate to Severe
Severe
20 (25.3%)
8 (10.1%)
21 (26.6%)
Aortic Regurgitation Moderate
Moderate to Severe
Severe
25 (19.8%)
4 (3.2%)
2 (1.6%)
Aortic Stenosis Moderate
Moderate to Severe
Severe
9 (19.2%)
1 (2.1%)
5 (10.6%)
Tricuspid Regurgitation Moderate
Moderate to Severe
Severe
29 (17.5%)
6 (3.6%)
12 (7.2%)
ePASP > 30mmHg 92 (52.0%)
Mean pressure = 43.8mmHg
LV Dysfunction 42 (20%)
17. Procedure type before death.
• Total deaths 102 (27.12%) out of 376 patients
total.
• Mean age of death 45.29 years. Youngest 14
oldest 87
Repair 12 (12.9%)
PBMV 5 (5.38%)
Bioprosthetic 41 (44.1%)
Mechanical 32 (34.4%)
1 2
3 5
6 7
9
Repair PBMV
Bioprosthetic Mechanical
Unknown
102 (27%) Dead
Procedure Type Before Death
18. Limitations
• Limited by its retrospective nature
• Time constraints imposed by no dedicated
funding/resource.
• Intraoperative TOE was not included in our
echocardiography results.
• Reliance on discharge letters and operative notes from
surgical referral centres - logistically difficult and labour
intensive.
• Data was manually extracted from various data sources
and manually inserted into our Surgical register, a potential
source of error.
19. Conclusion:
• Development of this RHD Clinical Register allows monitoring of
both single and multiple valve surgery patients from their initial
diagnosis of RHD.
• Likely to give insight into both short and long term surgical
outcomes and aid our understanding of prognostic indicators.
• Identify those patients who are lost to follow up and help the
ACCHS re-engage with those individuals.
• Complete and prospective data collection is ongoing and further
detailed analysis will be completed and presented at a later
date.
21. Case Study: Patient 1
• 1999-Diagnosed with RHD age 14
• 1997-2000-Recorded episodes of ARF age 12, 14 and 15 years.
• Had her first child age 15 years
• 2002-Mitral valve replacement Biograft, for severe MR, NYHA class 3 and
pulmonary hypertension age 17 years.
• Good outcome post first surgery
• 2003- recurrent pulmonary embolism on warfarin, paint sniffing, age 18.
• 2004- uncomplicated delivery of a baby boy age 19
• 2008- Petrol sniffing, alcohol abuse, domestic violence, depression, suicide
attempts age 23
• 2009- Mitral Valve and Aortic Valve replacement Biograft age 24
• Good outcome post second surgery
22. Case Study: Patient 1
• 2010- high risk delivery of baby interstate by LUSCS age 25
• 2013- Aortic and Mitral Mechanical Valve replacement age 28
• Surgery complication by prolonged ICCU admission with multiorgan
failure, biventricular failure, ionotropic dependant, severe pulmonary
hypertension with right heart failure, Septicaemia.
• 2014- Patients decision not for resuscitation or ICU admission- age 29
• April 2015-Cardiomyopathy with severe systolic dysfunction secondary to
rheumatic heart disease age 30.
• May 2015- NSTEMI
• Nov 2015- Hypoxic brain injury secondary to VF arrest
• 2016- Deceased age 30 years with 3 children age 15, 12 and 6 years old.
23. Aims
• Improve cardiac care of ACCHS patients attending our
clinic leading to reduced morbidity and mortality.
• Integration of primary cardiac care with specialist
cardiology services.
• Upskilling of the primary care team to address the
cardiac care needs of ACCHS patients.
• Improve the quality of care offered to our patients by
contributing to good health information and evidence
based medicine.
24. Method
• Collaborative exercise involving:
–Aboriginal Health Practitioner
–General Practitioner
–Clinic Nurse
–Cardiologist
–Echocardiographer
–Social Worker
–Admin staff in both ACCHS and Hospital setting.
• Designed a FARGP training post in Cardiology/Medicine supported by our
general practice regional training provider.
• Utilised AGPT funding to support the clinic allow the general practitioner leave
to upskill in the hospital setting.
25. Benefits and Challenges
• Benefits include:
–Reduced time to cardiology outpatient review and same day non interventional
diagnostics
–Better integration with tertiary level institutions
–Linking patients from specialist cardiology outpatients back in with their local
Aboriginal medical Service
• Challenges:
–Issues with tracking our clients for continual care and follow up due to transient
population
–Having capacity to address issues around social determinants, mental health
and wellbeing
–Complex patients require time to get to know and engage to effectively offer
best possible care.
26. Where to from here?
• Currently looking at data, before, during and after the Primary
Care Cardiology clinics which demonstrate improved access
to cardiology services.
• Ongoing support from local cardiology services in order to
continue with this model.
• Seek ongoing community support to maintain and build our
model to benefit ACCHS and their patients.
• Option in remote setting for 6 months training with cardiology
before moving to 6 months remote primary cardiac care.
28. Focused Cardiac Ultrasound
• Defined as, “a focused examination of the cardiovascular
system performed by a physician by using ultrasound as
an adjunct to the physical examination to recognise
specific ultrasonic signs that represent a narrow list of
potential diagnoses in specific clinical settings” (Spencer,
Kimura et al. 2013).
29. Background
• FCU allows significant improvement in speed and accuracy of diagnosis
of cardiac disease.
• Proven to change the diagnosis and management in 50% of patients in
the acute hospital setting and 20% of patients presenting to a
metropolitan general practice (Yates, Royse et al. 2016) (Canty, Royse
et al. 2012)
• ATSI patients represent a high risk population where earlier and more
accurate detection of cardiac disease may result in earlier and more
effective cardiac treatment.
• The University of Melbourne has developed a training system in FCU
and lung ultrasound that is accessible by a practitioner who has access
to the internet and an ultrasound simulator.
30. RACGP Indigenous Health Award 2017
• Pilot study in the training in the use of focused cardiac
ultrasound by primary care medical staff within an
Aboriginal Community Controlled Health Service. Its
feasibility and impact in the remote primary care
setting.
31. Aims
• Determine if General Practitioners, Nurse-Practitioners
and Aboriginal Health Practitioners within an ACCHS can
obtain basic competency in FCU knowledge base and
image acquisition and interpretation using an on-line and
simulator based teaching model.
• Secondary end-points include reliability of FCU applied
to patients and prevalence of structural cardiac disease
in the community.
32. Method
• Two-Centre observational study with 5 volunteer practitioners at each ACCHS
participate in an accredited point of care echocardiography training program.
• 2 phases of this study, expected to be completed within 6 months.
• 1-Knowledge base and image acquisition (2 months):
–Approximately 20 hours of pre-course multimedia reading, interpret 20
online interactive TTE case studies, attend a three-hour workshop and
perform and report FCU examinations on ten simulator pathology cases.
• 2-Application of FCU to patients (4 months):
–Each participant will perform 30 FCUs on patients attending clinic. The
images and interpretation report is submitted on-line for analysis by two
expert echocardiographers blinded to patient data.
–Outcomes include differences in report and image quality scores.
33. Significance and Innovation
• If this training system is effective then it could be used to train
a large number of medical staff in remote areas leading to a
rapid increase in the use of FCU in the remote primary care
setting, with major benefits to the health care of our high risk
groups.
34. Lung Ultrasound- Pulmonary Oedema
• A new visual stethoscope.
• Superior to CXR in diagnosis of pulmonary oedema (Volpicelli,
Caramello et al. 2008)
• Learning curve of < 10 examinations and fast to perform (requiring <
3 minutes) (Picano, Frassi et al. 2006)
• Diffuse B- lines allow bedside distinction between cardiogenic
pulmonary oedema versus a respiratory cause of acute dyspnoea
(Volpicelli, Elbarbary et al. 2012).
• Differentiating exacerbations of COPD, from decompensated heart
failure (Volpicelli, Cardinale et al. 2008).
36. References
• Jonathan R. Carapetis, F., FRACP, Jennifer R. Powers, BSC, Bart J. Cunie, FRACP, John F. Sangster,
FRACP, Alistair Begg, FRACP, Dale A. Fisher, FRACP, Charles J. Kilburn, FRACP, James N.C.
Burrow, FRACP (1999). "Outcomes Of Cardiac Valve Replacement For Rheumatic Heart Disease In
Aboriginal Australians." Asia Pacific Heart J 8(3).
• Lawrence, J. G., et al. (2013). "Acute rheumatic fever and rheumatic heart disease: incidence and
progression in the Northern Territory of Australia, 1997 to 2010." Circulation 128(5): 492-501.
• Roberts, K. V., et al. (2015). "Rheumatic heart disease in Indigenous children in northern Australia:
differences in prevalence and the challenges of screening." Med J Aust 203(5): 221 e221-227.
• Cannon, J., et al. (2017). "Rheumatic Heart Disease Severity, Progression and Outcomes: A Multi-
State Model." J Am Heart Assoc 6(3).
• Milne, R. J., et al. (2012). "Mortality and hospitalisation costs of rheumatic fever and rheumatic heart
disease in New Zealand." J Paediatr Child Health 48(8): 692-697.
• RHDAustralia (ARF/RHD writing group), National Heart Foundation of Australia and the Cardiac
Society of Australia and New Zealand. Australian guideline for prevention, diagnosis and management
of acute rheumatic fever and rheumatic heart disease (2nd edition). 2012
37. References
• Yates, J., et al. (2016). "Focused cardiac ultrasound is feasible in the general practice setting and
alters diagnosis and management of cardiac disease." Echo Res Pract 3(3): 63-69.
• Canty, D. J., et al. (2012). "The impact of focused transthoracic echocardiography in the pre-operative
clinic." Anaesthesia 67(6): 618-625.
• Canty, D. J., et al. (2012). "The impact of focused transthoracic echocardiography in the pre-operative
clinic." Anaesthesia 67(6): 618-625.
• Canty, D. J., et al. (2012). "The impact of pre-operative focused transthoracic echocardiography in
emergency non-cardiac surgery patients with known or risk of cardiac disease." Anaesthesia 67(7):
714-720.
• Canty, D., et al. (2016). "Comparison of practical and interpretive focused cardiac ultrasound learning
outcomes between a self-directed simulator and traditional live model course." Journal of
Cardiothoracic and Vascular Anesthesia 30: S30-S31.
• D. J. Canty, A. G. R., C. F. Royse (2015). "Self-directed simulator echocardiography training: a
scalable solution." Anaesth Intensive Care 43:3.
• Picano, E., et al. (2006). "Ultrasound lung comets: a clinically useful sign of extravascular lung water."
J Am Soc Echocardiogr 19(3): 356-363.
38. References
• Spencer, K. T., et al. (2013). "Focused cardiac ultrasound: recommendations from the American
Society of Echocardiography." J Am Soc Echocardiogr 26(6): 567-581.
• Volpicelli, G., et al. (2012). "International evidence-based recommendations for point-of-care lung
ultrasound." Intensive Care Med 38(4): 577-591.
• Volpicelli, G., et al. (2008). "Usefulness of lung ultrasound in the bedside distinction between
pulmonary edema and exacerbation of COPD." Emergency Radiology 15(3): 145-151.
• Volpicelli, G., et al. (2008). "Bedside ultrasound of the lung for the monitoring of acute decompensated
heart failure." Am J Emerg Med 26(5): 585-591.
39. Acknowledgement
• NACCHO
• A/Professor Nadarajah Kangaharan
• Dr Bo Remenyi
• Dr Marcus Ilton
• Dr Karen Dempsey
• Ms Claire Boardman
• Ms Rhiannon Townsend
• Dr Georgie Brunsdon
• A/Professor David J Canty
• Professor Rob A Baker
• Prof Bart Currie
• Ms Daphne Perry
• Dr James Stephen
• David Broman
• A/Professor Jayme Bennets
• Prof Colin Royse
• Prof Alistair Royse
• Prof Clare Heal
• Ms Maida Stewart
• Ms Marea Fittock
• Dr Nigel Gray
• Prof Brendan McAdam
• Professor Alan Cass
• Stephen Oat
• Richard Fejo
• Elisabeth Heenan
• Patricia Rankine
This presentation looks at our initial preliminary results from our descriptive analysis of outcomes of 236 patients who had their first RHD valve surgery between 1997 and 2016. Further survival analysis to follow.
Working across the top end of the Northern Territory, several patients in the remote and urban setting reported concern around the way there cardiac care was being managed in the primary care setting and would prefer to wait to see the cardiologist before any changes would be made to their medication and management. Sometimes waiting several months. They had completely lost confidence in their primary care provider to address their cardiac care needs and make what should be basic but necessary changes to their medications and management.
Last year I saw a young man in his late 20’s who was being treated for depression. He reported being lethargic, and unable to get out of bed for work in the mornings. This did indeed cause a deterioration in his mood as he had a young family to support. However on further questioning his initial symptoms were of heart failure, not depression. His transthoracic echo that day revealed a cardiomyopathy with an EF of 30%.
It can be difficult for remote primary care staff to confirm if dyspnoea is related to chronic lung disease or pulmonary oedema related to heart failure, not having available BNP blood testing to assist with diagnosis or CXR. At the end of this talk we will look at ways using ultrasound to address this.
How could we assist improve the care these patients received, to assist address the well documented morbidity and mortality related to cardiovascular disease.
Spoke to a retired GP who having worked over 30 yrs in communities, felt he never made a difference to the long term outcome of his ATSI patients. The emphasis was always on the immediate issues which left no time to look at long term outcomes to any great deal.
RHD incidence in the top end of the NT is 15/1000 (Roberts, Maguire et al. 2015).
RHD valve surgery accounted for 28% of admissions and 71% of the cost involved in the treatment of ARF and RHD.(Milne, Lennon et al. 2012)
Identify those at high risk of requiring further surgery.
Significant co morbidity in our study cohort comparting first and redo surgery.
LV dysfunction: first surgery 33 (16.4%) had LV dysfunction. Last Surgery 14 (22.9%)
Normal: First Procedure 170 (83.7%) Latest Procedure 47 (77%)
Mild: First Procedure 18 (8.9%) Latest Procedure 7 (11.5%)
Mild to Moderate: First Procedure 6 (3%) Latest Procedure 0 (0%)
Moderate: First Procedure 3 (1.5%) Latest Procedure 4 (6.5%)
Moderate to Severe: First Procedure 3 (1.5%) Latest Procedure 1 (1.6%)
Severe Impairment: First Procedure 3 (1.5%) Latest Procedure 2 (3.3%)
Initial and redo surgery
Family planning, adherence to medication and distance to travel to get monitoring for INR.
First Surgery: Out of 236 surgeries there were 201 MV Procedures. Mitral valve Repair 85 (42.29%), Biological 37 (18.41%), Mechanical 42 (20.90%), Percutaneous Balloon Mitral Valvuloplasty 37 (18.41%).
Last Surgery: Out of 64 patients there were 57 MV Procedures. Mitral Valve Repair 4 (6.9%), Biological 12 (20.69%), Mechanical 39 (67.24%), Percutaneous Balloon Mitral Valvuloplasty 2 (3.45%).
Aortic Valve is less likely to be repaired, the majority are replacements. There is an equal distribution between bioprosthetic and mechanical for the first surgery.
First Surgery: Out of 236 surgeries there were 64 AV Procedures. AVR Homograft 1 (1.56%), AVR Biological 25 (39.06%), AVR Mechanical 25 (39.06%), Aortic valve Repair 11 (17.19%),
Latest Surgery: Out of 64 Surgeries there were 25 AV Procedures. AVR Homograft 1 (4%), AVR Biological 3 (12.00%), AVR Mechanical 17 (68.0%), Aortic valve Repair 2 (8%), Ross Procedure 1 (4%).
NYHA Class
1 - 116 (53.4%)
2 - 46 (21.2%)
3 - 16 (7.37%)
4 - 19 (8.8%)
Unknown- 20 (9.2%)
Those with at least Moderate finding have the possibility of further surgery. Which shows these patients remain high risk after there procedures.
30% of Aboriginal people with RHD in the NT aged 10-19 years have MS often in association with MR.
Mean age of those with MS is 33 years. Generally progresses more rapidly in the ATSI population, with symptoms at a younger age.
AF is the most common complication of MS. PBMV is the treatment of choice in pure MS. MVA <1.5CM
tab mitralsten4
/*---------------------------------------------------------
mitralsten4 | Freq. Percent Cum.
------------+-----------------------------------
0 | 147 65.63 65.63
1 | 77 34.38 100.00
------------+-----------------------------------
Total | 224 100.00
-------------------------------------------
tab mitralstenosistype4
/*-------------------------------------------------------------
severity of mitral |
sten | Freq. Percent Cum.
-------------------+-----------------------------------
1=Normal | 2 2.53 2.53
2=Trivial | 2 2.53 5.06
3=Mild | 16 20.25 25.32
4=MildtoModerate | 10 12.66 37.97
5=Moderate | 20 25.32 63.29
6=ModeratetoSevere | 8 10.13 73.42
7=Severe | 21 26.58 100.00
-------------------+-----------------------------------
Total | 79 100.00
---------------------------------------------
Early contact with ACCHS patients by primary care staff while inpatient/CCU.
Patients reviewed with both cardiologist and GP in the hospital setting feeding back to AHP.
Improved cardiac care of ACCHS clients with aim to follow and monitor for improved long term outcomes.
Improved access of ACCHS patients to non interventional diagnostics.
Good health information is based on research studies we looked to improve the quality of care offered to our clients by contributing to good health information.
Most new health information is based on research studies
To improve health we need good information.
High risk patients with no ability to track progress once diagnosed
Integrated
Collaboration
Well documented morbidity and mortality related to cardiovascular disease
Patients having concerns about the standard of cardiac care receiving- not allowing General Practitioners to adjust there medication, waiting for cardiology referral to do so. Some times 3 months,
Remote primary care staff unable to confirm if dyspnoea related to COPD or pulmonary oedema not having available BNP blood testing to assist with diagnosis.
Aboriginal and Torres Strait Islander Salary Support Programme
Training Organisation Education Research Grants
Evidence based medicine within our environment.
No incentive for general practitioners to get involved in research.
Bringing Indigenous patients back to Aboriginal Medical Services
Well documented morbidity and mortality related to cardiovascular disease.
Patients having concerns about the standard of cardiac care receiving- not allowing General Practitioners to adjust there medication, waiting for cardiology referral to do so. Some times 3 months,
Remote primary care staff unable to confirm if dyspnoea related to COPD or pulmonary oedema not having available BNP blood testing to assist with diagnosis.
Most new health information is based on research studies
To improve health we need good information.
Evidence based medicine by primary care staff within primary care is required to improve primary care outcomes
Last year in a remote NT clinic. A young women presented for the 3rd time post cardiothoracic surgery with chest pain. Our NT Cardiac team happened to be there on the day of her last presentation. She had 3 young children by her side and was very unwell. She had an urgent echo which showed cardiac tamponade. She died in hospital 24 hrs later. This could have been prevented with the appropriate skill set of anyone in the clinic.
Cardiac abnormalities that have been accurately detected included the following:
-LV enlargement
-LV hypertrophy
-LV systolic function
-LA enlargement
-RV enlargement
-RV systolic function
-Pericardial effusion
-Inferior vena cava (IVC) size
Because these are beyond the experience of FCU training and experience, the following pathologies are unlikely to be accurately detected by FCU examination:
-aortic dissection,
-hypertrophic cardiomyopathy,
-LV regional wall-motion abnormalities,
-LV aneurysm,
-cardiac masses,
-RV hypertrophy,
-LV thrombus,
-valvular vegetations.
It is important to realize that most FCU studies are designed to evaluate the ability to image and interpret significant abnormalities, such as moderate or severe deviations from normal. Most abnormalities are defined by FCU users as present or absent. The broader experience to characterize pathologies into severities of abnormality should not be expected with FCU
When used by physicians without formal echocardiographic training, FCU is superior to physical examination for the detection of cardiac abnormalities, including LV enlargement, LV systolic dysfunction, LA enlargement, LV hypertrophy, pericardial effusion, and RA pressure elevation.
Defined by the American Society of Echocardiography as, “a focused examination of the cardiovascular system performed by a physician by using ultrasound as an adjunct to the physical examination to recognise specific ultrasonic signs that represent a narrow list of potential diagnoses in specific clinical settings” (Spencer, Kimura et al. 2013)
Focused cardiac ultrasound (FCU) is becoming an essential skill for all remote primary care providers, as it allows significant improvement in speed and accuracy of diagnosis of cardiac disease without the delay caused by referral to formal diagnostic laboratories.
FCU has been proven to change the diagnosis and management in approximately 50% of patients in the acute hospital setting and in 20% of patients presenting to the metropolitan general practice setting (Yates, Royse et al. 2016) (Canty, Royse et al. 2012)
Aboriginal and Torres Strait islanders represents a high-cardiac risk population where earlier and more accurate detection of cardiac disease may result in earlier and more effective cardiac treatment, which could lead to significantly improved health care and reduction in health costs saved in point of care use of FCU
The University of Melbourne has developed a training system in FCU and lung ultrasound that is accessible by a practitioner who has access to the internet and an ultrasound simulator (FCU TTE and FUSE Lung Ultrasound Course, ref.[ Canty DJ, Royse AG, Royse CF, (6,7). (D. J. Canty 2015) (Canty, Royse et al. 2012)
This training system has been successfully set up in metropolitan centres but not in the rural or remote setting, (Canty, Heiberg et al. 2017) (Canty, Barth et al. 2016)
One training program universal to all ACCHS. which is accredited, transferable, develops with technology and meets the changing needs of community over time, leading to both the empowerment and capacity building of the ACCHS workforce.
We propose task shifting (8) to build capacity using a focused cardiac ultrasound (FCU) training program for remote primary care staff to up-skill in the use of FCU to meet the needs of their community
Aim and Hypothesis: The primary aim of this prospective observational study is to determine if medical staff (physicians, nurse-practitioners and Aboriginal Health Practitioners) within an Aboriginal Community Controlled Health Service can obtain basic competency in FCU knowledge base and image acquisition and interpretation using an on-line and simulator based teaching model. Secondary aims include the number of FCU studies that are required to attain basic competency, and the accuracy of FCU compared with standard TTE and whether this has clinical significance.
Two-centre observational study.
5 volunteer learner practitioners at each Aboriginal Community Controlled Health Service who will participate in an accredited point of care echocardiography training program using the iHeartscan study protocol (University of Melbourne).
There are 2 phases of this study, which is expected to be completed within 9 months.
1.The learning course comprises knowledge base and image acquisition learning: (2 months), participants perform approximately 20 hours of pre-course multimedia reading, interpret 20 online interactive TTE case studies, attend a three-hour workshop and perform and report FCU examinations on ten simulator pathology cases, all of which is administered by an automated online system with activity-based triggers. Apart from the three-hour workshop, the entire course can be completed in the participant’s own time.
2. Application of FCU to patients. Each participant will be required to perform 30 FCUs on patients attending the clinic (4 months). The images and interpretation report is submitted on-line for analysis by two expert echocardiographers blinded to patient data. Outcomes include differences in report and image quality scores. The prevalence of structural cardiac disease will be determined in this sample, which will be used for development of larger outcome studies.
Multiple B- Lines are seen in both cardiogenic and non cardiogenic pulmonary oedema but diffuse B- lines allow bedside distinction between cardiogenic versus a respiratory cause of acute dyspnoea (Volpicelli, Elbarbary et al. 2012).
Confidence in diagnosis may be improved with echocardiography.
A key feature that separates pulmonary oedema from the other conditions causing Alveolar Interstitial Syndrome (AIS) is that in oedema the B-lines are typically less than 3mm apart. The B-Lines are usually bilateral, in adjacent areas without areas of skipping and are usually more prominent in the posterior lower zones, where associated pleural effusions are commonly seen.
As pulmonary oedema worsens, the density of B-Lines increases and may become confluent, appearing as a “snow storm”
In acute decompensated heart failure, the severity of oedema is proportional to the number of lung regions that contain B-Lines.
B-Lines appear and disappear in response to fluid loading and removal respectively and repeated interval lung scanning can be used to determine clinical progress and response to treatment.
Pulmonary fibrosis and cardiac disease may coexist, particularly in smokers and hence the ultrasound appearance alone may not distinguish between these disorders and the cardiac findings thus clinical context is important.
COPD: Lung Ultrasound findings usually normal. However as associated prolonged expiratory time and shortened inspiratory time is seen on M-mode lung service ultrasound.
Other reversible causes of respiratory distress can be excluded with ultrasound which include pneumothorax, consolidation, atelectasis from mucous plugging and AIS.
Echocardiography is important to look for secondary right and left ventricular failure.
Fig. 1 A, Normal transthoracic ultrasound (US) lung scan with no vertical artifacts (comet tails or B lines). B, Longitudinal US lung scan for
the detection of the pleural line between 2 adjacent ribs (“bat sign”). C, Oblique transthoracic US lung scan with B+ in a patient with ADHF. D,
Multiple and large B lines that fuse (“shining” or “white” lung) in a patient admitted with ADHF and advanced pulmonary edema.
B Lines- roughly vertical, is a comet tail artifact that has 5 mandatory features: it arises from the pleural line, it is well defined like a laser beam, it spreads to the edge of the screen without fading, it erases A lines, and it moves with lung sliding
Once the sonographic image of the pleural line was detected through location of the ribs and visualization of the “bat sign” (pleura line under 2 adjacent ribs, see Fig. 1B) [19],we turned the probe to obtain the intercostal scan with the maximum extension of the visible pleura (oblique scan, see Fig. 1C).
Period1845–1852
Total deaths 1 million
Population fell by 20–25% due to mortality and emigration
Kindred Spirits
Generosity of a Native American tribe towards the people of Ireland at the height of the Great Famine
Eagle feathers, arranged in a circular shape and reaching towards the sky, is a metaphorical representation of a bowl filled with food, presented to the hungry.
The Choctaw Nation of the south eastern states of America, in 1847 raised $170 – worth tens of thousands of dollars today – from their meagre resources to aid those starving in Ireland.
“They bestowed a blessing not only on the starving Irish men, women and children, but also on humanity. The gift from the Choctaw people was a demonstration of love and this monument acknowledges that and hopefully will encourage the Irish people to act as the Choctaw people did.”
“Your story is our story. We didn’t have any income. This was money pulled from our pockets. We had gone through the biggest tragedy that we could endure, and saw what was happening in Ireland and just felt compelled to help,”
