Infective endocarditis following Melody valve implantation: comparison with a surgical cohort.

BACKGROUND: Infective endocarditis has been reported post Melody percutaneous pulmonary valve implant; the incidence and risk factors, however, remain poorly defined. We identified four cases of endocarditis from our first 25 Melody implants. Our aim was to examine these cases in the context of postulated risk factors and directly compare endocarditis rates with local surgical valves. METHODS: We conducted a retrospective review of patients post Melody percutaneous pulmonary valve implant in New Zealand (October, 2009-May, 2015) and also reviewed the incidence of endocarditis in New Zealand among patients who have undergone surgical pulmonary valve implants. RESULTS: In total, 25 patients underwent Melody implantation at a median age of 18 years. At a median follow-up of 2.9 years, most were well with low valve gradient (median 27 mmHg) and only mild regurgitation. Two patients presented with life-threatening endocarditis and obstructive vegetations at 14 and 26 months post implant, respectively. Two additional patients presented with subacute endocarditis at 5.5 years post implant. From 2009 to May, 2015, 178 surgical pulmonic bioprostheses, largely Hancock valves and homografts, were used at our institution. At a median follow-up of 2.9 years, four patients (2%) had developed endocarditis in this group compared with 4/25 (16%) in the Melody group (p=0.0089). Three surgical valves have been replaced. CONCLUSIONS: The Melody valve offers a good alternative to surgical conduit replacement in selected patients. Many patients have excellent outcomes in the medium term. Endocarditis, however, can occur and if associated with obstruction can be life threatening. The risk for endocarditis in the Melody group was higher in comparison with that in a contemporaneous surgical pulmonary implant cohort.

Recognition of and care-seeking for maternal and newborn complications in Jayawijaya district, Papua province, Indonesia: a qualitative study.

BACKGROUND: Indonesia's progress on reducing maternal and newborn mortality rates has slowed in recent years, predominantly in rural areas. To reduce maternal and newborn mortality, access to quality and skilled care, particularly at the facility level, is crucial. Yet, accessing such care is often delayed when maternal and newborn complications arise. Using the "Three Delays" model originated by Thaddeus and Maine (1994), investigation into reasons for delaying the decision to seek care, delaying arrival at a health facility, and delaying the receiving of adequate care, may help in establishing more focused interventions to improve maternal and newborn health in this region. METHODS: This qualitative study focused on identifying, analyzing, and describing illness recognition and care-seeking patterns related to maternal and newborn complications in the Jayawijaya district of Papua province, Indonesia. Group interviews were conducted with families and other caregivers from within 15 villages of Jayawijaya who had either experienced a maternal or newborn illness or maternal or newborn death. RESULTS: For maternal cases, excessive bleeding after delivery was recognized as a danger sign, and the process to decide to seek care was relatively quick. The decision-making process was mostly dominated by the husband. Most care was started at home by birth attendants, but the majority sought care outside of the home within the public health system. For newborn cases, most of the caregivers could not easily recognize newborn danger signs. Parents acted as the main decision-makers for seeking care. Decisions to seek care from a facility, such as the clinic or hospital, were only made when healthcare workers could not handle the case within the home. All newborn deaths were associated with delays in seeking care due to caretaker limitations in danger sign identification, whereas all maternal deaths were associated with delays in receiving appropriate care at facility level. CONCLUSIONS: For maternal health, emphasis needs to be placed on supply side solutions, and for newborn health, emphasis needs to be placed on demand and supply side solutions, probably including community-based interventions. Contextualized information for the design of programs aimed to affect maternal and newborn health is a prerequisite.