Traditional medicine use in Timor-Leste.

BACKGROUND: Traditional medicine use is common amongst peoples in developing nations. Timor-Leste is no exception. However little is known about the prevalence, pattern, satisfaction with, cost or type of traditional medicine used in Timor-Leste. This study aims to describe the prevalence, nature and basic demographic factors associated with contemporary traditional medicine use in Timor-Leste. METHODS: A structured interview questionnaire was administered in Tetun to 50 surgical patients, 50 internal medicine patients, 50 hospital staff and 50 hospital visitors at Hospital Nacional Guido Valadares, Timor-Leste's major referral hospital. RESULTS: 60% of respondents reported having used traditional medicine; 32% within the last year. The greatest use was amongst surgical patients, the least amongst hospital staff. The frequency of traditional medicine use was comparable amongst all groups regardless of size of community, residence or level of education. Traditional medicine use in Timor-Leste is sufficiently common to represent part of the cultural norm. Factors described as promoting traditional medicine use included cost, limited access to other medical services and a belief that traditional medicine was free of side effects. Approximately half the patients reported using traditional medicine for their current illness and many for chronic illness in conjunction with conventional medicine. CONCLUSION: Traditional medicine use is common in Timor-Leste. Medical practitioners need to be cognizant of the common and potentially concomitant use of traditional medicine alongside conventional medicine when treating patients in Timor-Leste.

"Emerging Technologies and Medical Countermeasures to Chemical, Biological, Radiological, and Nuclear (CBRN) Agents in East Ukraine".

Since 2014, Ukraine has been beset by an armed conflict with international and internal dimensions. The nature of this conflict is multidimensional, and disaster preparedness and response in this context must be as well. Health experts from Ukraine, the United States of America, United Kingdom, Czech Republic, and Norway convened for an educational event in Dnipro, East Ukraine on November 11-15, 2019. At the event, "Emerging Technologies and Countermeasures to CBRN Agents: Advanced Training Response to Conflict and Security Challenges in East Ukraine," over 1,000 participants participated in panel discussions, didactic lectures, and an advanced training on various dimensions of disaster response. This report provides an overview of the key discussions and outcomes of the event.

Neonatal anesthesia in low birth weight babies at Hospital Nacional Guido Valadares, Dili, Timor-Leste.

Over a 6-month period, eight neonates weighing less than 3 kg were operated on at Hospital Nacional Guido Valadares, Dili, Timor-Leste. Each was operated on for an abdominal condition. There is no postoperative neonatal ventilation, neonatal inotropes, fluid warmers, or parenteral nutrition available at Hospital Nacional Guido Valadares. Medical air and nitrous oxide are unavailable. Oxygen from cylinders is the only gas available in theaters and on the wards. Generally equipment is problematic and not designed for neonates. Five of these infants perished in hospital perioperatively, representing an in-hospital mortality of 62%, another is presumed to have died following discharge, and two recovered well. This represents an estimated overall mortality rate of 75%. This is not surprising given the difficult circumstances in theater and the limited postoperative support services available. The resources and time deployed in operating on these small neonates is significant. As difficult as it may be surgical enthusiasm and the uncertainties surrounding prognostication should not displace practical and realistic assessment of the likely outcome of operating on very small babies in low resource facilities where perioperative support is limited. Future development in the Timor-Leste healthcare sector will hopefully provide an environment where improvements in outcome can be achieved.

Predicting postoperative morphine consumption in children.

BACKGROUND: Morphine is the most commonly used postoperative analgesic for moderate to severe pain in paediatric patients, but there is little research into predictive factors correlating with postoperative morphine consumption. METHODS: All patients undergoing surgery who received morphine postoperatively over eight months were prospectively enrolled. Data analysed included total morphine consumption to day 3, age, weight, type of surgery, ASA status, preoperative opioid administration, predicted postoperative pain intensity (according to French Society of Anaesthesiology and Intensive Care classification) and surgery duration. Two cohorts were constructed: the first over 6months to construct a statistical model and the second over 2months to validate the model. ANOVA univariate analyses and multivariate linear analysis were performed. RESULTS: One hundred and fifty-three patients were included in the construct cohort and 40 in the validation cohort. Multivariate analysis demonstrated that total morphine consumption through postoperative day 3 was independently increased by a decreased age, female gender, an increased duration of surgery and an increased morphine titration in PACU. Overall, the model explained 57% of morphine requirement variability. When the model was applied to the validation cohort, a significant correlation was demonstrated between observed and predicted values: r=0.67, P<0.0001. CONCLUSION: Age, gender, duration of surgery and doses of titrated morphine in PACU proved to be strong predictors of postoperative morphine consumption by day 3 during paediatric surgery. Knowledge of such factors may help clinicians to better manage postoperative pain in children.

Intraoperative changes in blood pressure associated with cerebral desaturation in infants.

BACKGROUND: Intraoperative hypotension has been linked to poor postoperative neurological outcomes. However, the definition of hypotension remains controversial in children. We sought to determine arterial blood pressure threshold values associated with cerebral desaturation in infants. METHODS: After ethics committee approval, infants younger than 3 months were included in this prospective observational study. Cerebral saturation was assessed using near-infrared spectroscopy. The primary goal of the study was to determine percentage reductions in intraoperative systolic blood pressure (SBP) and mean blood pressure (MBP) associated with decreases in cerebral blood oxygen saturation of >20%, when compared to baseline. Analyses were performed using a bootstrap receiving operator characteristic (ROC) curves with determination of the gray zone. RESULTS: Sixty patients were recruited and 960 measurement points were recorded. Fifty-nine data points (6.1%) recorded cerebral desaturation of >20% when compared to baseline. The areas under the ROC curves were 0.79 (0.74-0.84) and 0.67 (0.6-0.75) for percentage decreases in SBP and MBP, respectively. Gray zone values with false-positive and negative rates <10% were SBP decreases of 20.5% and 37.5%, respectively, and MBP decreases of 15.5% and 44.5%, respectively. CONCLUSION: Our results indicate that falls in noninvasive systolic blood pressure of <20% from baseline are associated with a <10% chance of cerebral desaturation in neonates and infants <3 months of age undergoing noncardiac surgery. As such, maintaining systolic blood pressure above this threshold value appears a valid clinical target.

Alternative medicine use at Vila Central Hospital: a survey of 'custom medicine' use in patients and staff a decade later.

A structured questionnaire was administered to 50 medical patients, 50 surgical patients and 50 staff members at Vila Central Hospital, Vanuatu. A similar study was conducted 10 years earlier. In the intervening decade, Vanuatu has seen unprecedented population growth, increasing expatriate numbers, and the introduction of mobile phone and Internet networks. Given these social transformations, this study aimed to identify changes in custom medicine use over this period. Fifty-nine percent of interviewees had used custom medicine at least once, compared to 86% reported in the 2003 study. Thirty-two percent had used custom medicine in the last 12 months, a significant decline from 60% in the previous study. Collectively, rates of custom medicine use have declined but especially in the physical therapies such as bone setting. We believe this declining custom medicine use reflects an overall weakening traditional culture within Vanuatu and believe that within a generation, custom medicine knowledge will likely be lost.

Postoperative pain management in children and infants: an update.

Many factors contribute to suboptimal pain management in children. Current evidence suggests that severe pain in children has significant long-lasting effects, even more so than in adults. In particular, recent evidence suggests a lack of optimal postoperative pain management in children, especially following ambulatory surgery. This review provides simple guidelines for the management of postoperative pain in children. It discusses the long-term effects of severe pain and how to evaluate pain in both healthy and neurologically impaired children, including neonates. Currently available treatment options are discussed with reference to the efficacy and side effects of opioid and non-opioid and regional analgesic techniques. The impact of preoperative anxiety on postoperative pain, and the efficacy of some nonpharmacological techniques such as hypnosis or distraction, are also discussed. Finally, basic organizational strategies are described, aiming to promote safer and more efficient postoperative pain management in children.

Mortality and outcomes of elderly patients admitted to the intensive care unit at Cairns Base Hospital, Australia.

OBJECTIVE: To determine the survival and outcome of elderly patients admitted to the intensive care unit at Cairns Base Hospital. METHODS: A retrospective review of patients aged 60 years or over admitted to the ICU (a Level 2 general unit) at Cairns Base Hospital, a regional hospital in Queensland, during 2003-2005. Mortality was determined by review of hospital records, the Queensland register of deaths, and direct patient or family contact in November 2006. Demographic and clinical details were collected, and the EuroQol-5D questionnaire was used to assess current and pre-ICU quality of life. RESULTS: 432 patients aged >or= 60 years had 469 admissions to the ICU during 2003-2005. Long-term outcome was determined for 68%: 201 (46%) were confirmed dead, and 94 (22%) were confirmed alive, while the outcome for 137 (32%) remained unknown. Allowing for an estimated mortality of 39% in the unknown group, the overall estimated mortality was 60%. Mean follow-up time was 2.4 (SD, 0.9) years (range, 11-35 months). As age increased, mortality increased: 37% for the 60-70 years age group; 50% for 70-80 years; 61% for 80-90 years, and 83% for > 90 years. The quality of life of survivors was lower on follow-up than on ICU admission. CONCLUSIONS: Elderly patients admitted to the ICU have high mortality. As age increases, mortality increases. Elderly survivors can expect a lower quality of life after an ICU admission, although on average the difference is not great.

Travel insurance and medical evacuation: view from the far side.

Travel insurers and medical evacuation companies have a responsibility to provide an efficient high-quality service to their clients. These companies often deliver a standard far short of best practice and far short of their promotional brochures. Their services are overdue for governmental review and a lifting of standards. Travellers must be given realistic advice about the risks of foreign travel and that healthcare resources at their destination may be very limited. Travellers must check with their insurer that the policy they buy truly meets their needs. Some people should not travel overseas.

Alternative medicine use at Vila Central Hospital Vanuatu: a survey of the use of 'custom medicine' in patients and staff.

A structured questionnaire was developed to assess the use of custom (traditional or herbal) medicine in 50 medical and 50 surgical inpatients and 50 staff at Vila Central Hospital, Vanuatu. Eighty-six per cent of those interviewed had used custom medicine at least once, 60% within the last year. Twenty-one medical patients (42%) had used custom medicine for their current problem, 12% whilst in hospital. Eighteen surgical patients (36%) had used custom medicine for their current problem, 6% whilst in hospital. Fourteen of the staff (28%) interviewed had used custom medicine within the last year. Sixty-nine per cent of interviewees stated that custom medicine had improved their condition. Whilst custom medicine use was common across all attained education levels, there was a trend for those with higher levels of education to use less custom medicine. The most common form of custom medicine was leaf tea, followed by leaf applications, cutting, magic, massage and chanting. The majority of these were made/prescribed by local 'Klevas' (custom doctors). The cost of the 'medicine' was often substantial, generally many times the cost of a day in hospital. These findings indicate a high prevalence of custom medicine use within Vanuatu. Clinicians must be alert to the possibility of their patients using custom medicine even whilst in hospital and the potential for custom medicine to contribute to the clinical problems. Late presentation of patients to hospital is common in Vanuatu, and the use of custom medicine is partially a contributing factor to this. It also poses questions as to patient confidence in health services.

Twenty-three years of labour floor records, Vila Central Hospital, Vanuatu.

Vanuatu is an island nation in the south-west Pacific. Vila Central Hospital (VCH) is the country's major referral hospital. The handwritten labour floor records from VCH between 1979 and 2001 were examined and collated. During this period 28,638 women received care. The mean Caesarean section and instrumental delivery rate were 5.2% (2.1-8.2% per annum) and 1.8% (0.9-3.2% per annum), respectively. The post-partum haemorrhage rate fell from >5% in 1979 to <1% in 2001. The overall hospital maternal mortality rate was 7/10,000. These records represent the largest published series of labour floor data collected from any Pacific island nation.

Kava drinking in Vanuatu--a hospital based survey.

Kava is an intoxicating non-fermented beverage native to the Pacific Islands. In Vanuatu men traditionally drank kava on ceremonial occasions. Now however men and women drink kava on a casual basis. To assess the kava-drinking habits of current-day ni-Vanuatu, 150 people were surveyed at Vila Central Hospital, (50 medical and 50 surgical patients plus 50 staff). 35% of those surveyed drank kava, (9% daily). 59% of men and 15% of women drank kava (approximately 4:1). 51% of all men drank kava at least weekly, compared to 11% of women. For any given kava-drinking episode men drank more than women, (4.3 +/- 2 vs 3.3 +/- 1.3 shells). There was no significant difference in age between drinkers and non-drinkers or in usage rates between patient groups or staff. Women attaining higher levels of education and women resident on Vanuatu's main island were more likely to drink kava. Of the women surveyed who were resident on outer islands none drank kava. This study reveals that the consumption of fresh kava on a regular basis is very common in Vanuatu. If this is the case it also suggests that whilst much is written about the dermopathy, weight loss and, more recently, possible liver disease associated with kava use that these and other health problems are of doubtful significance. This is also supported by field experience.

Population, public health and tubal ligation in Vanuatu.

The association between population growth and public health is often neglected. Between 1989 and 1999 Vanuatu's population grew by 30%. Unless this growth slows existing public health problems will worsen. To gain insight into family planning habits 111 ni-Vanuatu women undergoing tubal ligation were surveyed. 85% had 4, or more, children. Women resident on the outer islands had more children than those on the island containing the nation's capital. The implication is that ni-Vanuatu women perceive 4 children as desirable. With approximately half the population entering their reproductive years in the next decade this is too many to avoid a population explosion in Vanuatu. Public health campaigns must promote the benefits of a small family. Urgent education and widespread provision of effective family planning is required to avoid a future public health crisis. Aid donors need to be made aware of this as an absolute priority.