Indigenous Populations In Australia Research Articles

40 years of the human T-cell leukemia virus: past, present, and future.

It has been nearly 40 years since human T-cell leukemia virus-1 (HTLV-1), the first oncogenic retrovirus in humans and the first demonstrable cause of cancer by an infectious agent, was discovered. Studies indicate that HTLV-1 is arguably one of the most carcinogenic agents to humans. In addition, HTLV-1 causes a diverse array of diseases, including myelopathy and immunodeficiency, which cause morbidity and mortality to many people in the world, including the indigenous population in Australia, a fact that was emphasized only recently. HTLV-1 can be transmitted by infected lymphocytes, from mother to child via breast feeding, by sex, by blood transfusion, and by organ transplant. Therefore, the prevention of HTLV-1 infection is possible but such action has been taken in only a limited part of the world. However, until now it has not been listed by the World Health Organization as a sexually transmitted organism nor, oddly, recognized as an oncogenic virus by the recent list of the National Cancer Institute/National Institutes of Health. Such underestimation of HTLV-1 by health agencies has led to a remarkable lack of funding supporting research and development of treatments and vaccines, causing HTLV-1 to remain a global threat. Nonetheless, there are emerging novel therapeutic and prevention strategies which will help people who have diseases caused by HTLV-1. In this review, we present a brief historic overview of the key events in HTLV-1 research, including its pivotal role in generating ideas of a retrovirus cause of AIDS and in several essential technologies applicable to the discovery of HIV and the unraveling of its genes and their function. This is followed by the status of HTLV-1 research and the preventive and therapeutic developments of today. We also discuss pending issues and remaining challenges to enable the eradication of HTLV-1 in the future.

Echocardiography in Pregnant Indigenous Australians: Need for Screening?

The Indigenous population of Australia has one of the highest rates of rheumatic heart disease (RHD) globally. RHD is more common in females and peak incidence corresponds with child-bearing age. Significant valvular disease can complicate pregnancy. In the Northern Territory, pregnant women are referred for echocardiogram if there are signs or symptoms of cardiac pathology or a history of RHD. To assess the current practice of echocardiography in pregnant women in a region with a high prevalence of RHD. A retrospective review of all echocardiograms performed between 2014–2018 for an indication relating to pregnancy was completed. Data included indication, clinical history, echocardiographic findings and location of delivery. A total of 322 cases with echocardiography during pregnancy were reviewed, 195 Indigenous and 127 non-indigenous women (mean age 25 vs 30 years, p-value <0.01). Indigenous women had significantly higher rates of abnormal echocardiograms (35.9% vs 10%, p-value <0.01) and higher burden of rheumatic fever/RHD (39.4% vs 0.8% p-value <0.01). Moderate or severe valve lesions were detected in 26 (13.3%) indigenous women and 11 (5.6%) had previous cardiac surgery. Transfer to a tertiary centre with valve intervention services available was required for 12 (6.2%) Indigenous women. In the Northern Territory, Indigenous pregnant women have significantly higher rates of abnormal echocardiograms compared with non-indigenous counterparts. This is mainly due to RHD. Data suggests that Indigenous pregnant women are being under serviced by the current referral practices. Guidelines are urgently needed in relation to echocardiography and pregnancy in populations that are burdened by RHD.

Financial Stress and Indigenous Australians

We examine the high levels of financial stress among Indigenous populations in Australia. We estimate separate models for the determinants of financial stress for Indigenous and non‐Indigenous households and show the importance of separately considering Indigenous disadvantage. We use these models to build equivalence scales for both groups. We find evidence consistent with financial stress being exacerbated by demand sharing (‘humbugging’). The evidence also suggests that financial stress is reduced by engagement in traditional hunting and gathering activities.

Cannabis Use Among Remote Indigenous Australians: Opportunities to Support Change Identified in Two Waves of Sampling.

Background: Cannabis harms among Indigenous populations in Australia, New Zealand, Canada and the United States may be magnified by poorer health and heavy use. However, little direct evidence is available to evaluate cannabis' impacts. In communities in remote northern Queensland (Australia) where cannabis has become endemic, opportunities to support change were investigated.Methods: Opportunistically recruited participants (aged 15–49 years) discussed their cannabis use history in interviews in two waves of population sampling in Cape York (Queensland). Wave 1 included 429 people (235 males and 194 females); and wave 2 included 402 people (228 males and 174 females). Current users (used cannabis during the year before interview) described frequency of use, amount consumed, expenditure and dependence symptoms. Other substance use was recorded for 402 people at wave 2.Results: Wave 1: 69% reported lifetime use and 44% current use. Males (55%) were more likely than females (30%) to be current users (P < 0.001). Most (96%) current users described at least weekly use; nearly half (48%) were “heavy” users (≥6 cones/session at least once/week) and 77% met cannabis dependence criteria. Three communities spent up to $AUD14,200/week on cannabis, around $AUD2.0 million/year, or around 9% of community people's total income on cannabis. The majority (79%) of current users wanted to quit or reduce their cannabis use. Wave 2: no difference was observed in the proportion of lifetime (69%, |z| = 0.04, P = 0.968) or current cannabis users (39%, |z| = 1.39, P = 0.164); nor current use among males (71%, |z| = 0.91, P = 0.363) or females (62%, |z| = 0.36, P = 0.719). However, a significant reduction in current users by 15% (|z| = 2.36, P = 0.018) was observed in one community. Of 105 wave 1 current users re-assessed in 2, 29 (27%) had ceased use. These participants reported cost and family commitments as reasons to change and that social support and employment enabled abstinence. Current and lifetime cannabis use were closely associated with all other substance use, particularly tobacco and alcohol (both P > 0.001).Conclusions: High rates of heavy cannabis use in remote Australian Indigenous communities warrant action. Successful cessation among some individuals suggests that significant opportunities are available to support change even where cannabis use may be endemic.

Community-based interventions to address alcohol and drug use in Indigenous populations in Australia, New Zealand and Canada: a systematic review protocol.

What is the effectiveness of community-based interventions designed to reduce harm associated with alcohol and other drug use in Indigenous populations in Australia, New Zealand and Canada?

Enhanced primary mental healthcare for Indigenous Australians: service implementation strategies and perspectives of providers

BackgroundImproving access to culturally appropriate mental healthcare has been recognised as a key strategy to address the often greater burden of mental health issues experienced by Indigenous populations. We present data from the evaluation of a national attempt at improving access to culturally appropriate mental healthcare for Indigenous Australians through a mainstream primary mental healthcare program, the Access to Allied Psychological Services program, whilst specifically focusing on the implementation strategies and perspectives of service providers.MethodsWe conducted semi-structured interviews with 31 service providers (primary care agency staff, referrers, and mental health professionals) that were analysed thematically and descriptively.ResultsAgency-level implementation strategies to enhance service access and cultural appropriateness included: the conduct of local service needs assessments; Indigenous stakeholder consultation and partnership development; establishment of clinical governance frameworks; workforce recruitment, clinical/cultural training and supervision; stakeholder and referrer education; and service co-location at Indigenous health organisations. Dedicated provider-level strategies to ensure the cultural appropriateness of services were primarily aimed at the context and process of delivery (involving, flexible referral pathways, suitable locations, adaptation of client engagement and service feedback processes) and, to a lesser extent, the nature and content of interventions (provision of culturally adapted therapy).ConclusionsThis study offers insights into key factors underpinning the successful national service implementation approach. Study findings highlight that concerted national attempts to enhance mainstream primary mental healthcare for Indigenous people are critically dependent on effective local agency- and provider-level strategies to optimise the integration, adaptation and broader utility of these services within local Indigenous community and healthcare service contexts. Despite the explicit provider focus, this study was limited by a lack of Indigenous stakeholder perspectives. Key study findings are of direct relevance to inform the future implementation and delivery of culturally appropriate primary mental healthcare programs for Indigenous populations in Australia and internationally.

Establishing Smoke-Free Homes in the Indigenous Populations of Australia, New Zealand, Canada and the United States: A Systematic Literature Review.

A smoke-free home can have multiple benefits by reducing exposure to secondhand smoke (SHS), supporting quit attempts among active smokers, and discouraging adolescents from taking up smoking. The aim of this review was to summarize the literature on the establishment of smoke-free homes in Indigenous populations and identify the supporting influences and barriers, using the Social Cognitive Theory lens. A search of the Medline, CINAHL, Cochrane Collaboration and PyscINFO databases and manual searches of relevant peer-reviewed literature was completed, focusing on Indigenous populations in developed economies of North America and Oceania. Of 2567 articles identified, 15 studies were included. Ten studies included Indigenous participants only, and of these just three focused entirely on SHS in the home. Knowledge of the harms associated with SHS was the most common theme represented in all the studies. This knowledge fueled parents’ motivation to protect their children from SHS by establishing smoke-free homes. Individuals who approached implementation with confidence, coupled with clear communication about smoke-free home rules were more successful. Barriers included challenges for families with multiple smokers living in the same dwelling. There is limited research regarding managing smoking behaviors in the home among Indigenous populations, even though this approach is a successful catalyst for smoking prevention and cessation. Research to understand the influences that support the establishment of smoke-free homes is required for better-informed intervention studies.

Indigenous Australian household structure: a simple data collection tool and implications for close contact transmission of communicable diseases.

Households are an important location for the transmission of communicable diseases. Social contact between household members is typically more frequent, of greater intensity, and is more likely to involve people of different age groups than contact occurring in the general community. Understanding household structure in different populations is therefore fundamental to explaining patterns of disease transmission in these populations. Indigenous populations in Australia tend to live in larger households than non-Indigenous populations, but limited data are available on the structure of these households, and how they differ between remote and urban communities. We have developed a novel approach to the collection of household structure data, suitable for use in a variety of contexts, which provides a detailed view of age, gender, and room occupancy patterns in remote and urban Australian Indigenous households. Here we report analysis of data collected using this tool, which quantifies the extent of crowding in Indigenous households, particularly in remote areas. We use these data to generate matrices of age-specific contact rates, as used by mathematical models of infectious disease transmission. To demonstrate the impact of household structure, we use a mathematical model to simulate an influenza-like illness in different populations. Our simulations suggest that outbreaks in remote populations are likely to spread more rapidly and to a greater extent than outbreaks in non-Indigenous populations.

Antibiotics for persistent cough or wheeze following acute bronchiolitis in children.

Bronchiolitis is a common acute respiratory condition with high prevalence worldwide. This clinically diagnosed syndrome is manifested by tachypnoea (rapid breathing), with crackles or wheeze in young children. In the acute phase of bronchiolitis (≤ 14 days), antibiotics are not routinely prescribed unless the illness is severe or a secondary bacterial infection is suspected. Although bronchiolitis is usually self-limiting, some young children continue to have protracted symptoms (e.g. cough and wheezing) beyond the acute phase and often re-present to secondary care. To compare the effectiveness of antibiotics versus controls (placebo or no treatment) for reducing or treating persistent respiratory symptoms following acute bronchiolitis within six months of acute illness. We searched the following databases: the Cochrane Airways Group Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), the World Health Organization (WHO) trial portal, the Australian and New Zealand Clinical Trials Registry, and ClinicalTrials.gov, up to 26 August 2016. We included randomised controlled trials (RCTs) comparing antibiotics versus controls (placebo or no treatment) given in the post-acute phase of bronchiolitis (> 14 days) for children younger than two years with a diagnosis of bronchiolitis. Two review authors independently assessed studies against predefined criteria, and selected, extracted, and assessed data for inclusion. We contacted trial authors for further information. In this review update, we added one study with 219 children. A total of two RCTs with 249 children (n = 240 completed) were eligible for inclusion in this review. Both studies contributed to our primary and secondary outcomes, but we assessed the quality of evidence for our three primary outcomes as low, owing to the small numbers of studies and participants; and high attrition in one of the studies. Data show no significant differences between treatment groups for our primary outcomes: proportion of children (n = 249) who had persistent symptoms at follow-up (odds ratio (OR) 0.69, 95% confidence interval (CI) 0.37 to 1.28; fixed-effect model); and number of children (n = 240) rehospitalised with respiratory illness within six months (OR 0.54, 95% CI 0.05 to 6.21; random-effects model). We were unable to analyse exacerbation rate because studies used different methods to report this information. Data showed no significant differences between treatment groups for our secondary outcome: proportion of children (n = 240) with wheeze at six months (OR 0.47, 95% CI 0.06 to 3.95; random-effects model). One study reported bacterial resistance, but only at 48 hours (thus with limited applicability for this review). Another study reported adverse events from which all children recovered and remained in the study. Current evidence is insufficient to inform whether antibiotics should be used to treat or prevent persistent respiratory symptoms in the post-acute bronchiolitis phase. Future RCTs are needed to evaluate the efficacy of antibiotics for reducing persistent respiratory symptoms. This is particularly important in populations with high acute and post-acute bronchiolitis morbidity (e.g. indigenous populations in Australia, New Zealand, and the USA).

Assessing service use for mental health by Indigenous populations in Australia, Canada, New Zealand and the United States of America: a rapid review of population surveys

BackgroundIndigenous people in Australia, Canada, New Zealand and the United States of America experience disproportionately poor mental health compared to their non-Indigenous counterparts. To optimally allocate resources, health planners require information about the services Indigenous people use for mental health, their unmet treatment needs and the barriers to care. We reviewed population surveys of Indigenous people to determine whether the information needed to guide service development is being collected.MethodsWe sought national- or state-level epidemiological surveys of Indigenous populations conducted in each of the four selected countries since 1990 that asked about service use for mental health. Surveys were identified from literature reviews and web searches. We developed a framework for categorising the content of each survey. Using this framework, we compared the service use content of the surveys of Indigenous people to each other and to general population mental health surveys. We focused on identifying gaps in information coverage and topics that may require Indigenous-specific questions or response options.ResultsNine surveys met our inclusion criteria. More than half of these included questions about health professionals consulted, barriers to care, perceived need for care, medications taken, number, duration, location and payment of health professional visits or use of support services or self-management. Less than half included questions about interventions received, hospital admissions or treatment dropout. Indigenous-specific content was most common in questions regarding use of support services or self-management, types of health professionals consulted, barriers to care and interventions received.ConclusionsEpidemiological surveys measuring service use for mental health among Indigenous populations have been less comprehensive and less standardised than surveys of the general population, despite having assessed similar content. To better understand the gaps in mental health service systems for Indigenous people, systematically-collected subjective and objective indicators of the quality of care being delivered are needed.

Teaching Cultural Competence in Dental Education: A Systematic Review and Exploration of Implications for Indigenous Populations in Australia

Indigenous and other minority populations worldwide experience higher rates of disease including poor oral health than other populations. Cultural competence of practitioners is increasingly being recognized as fundamental to health care and quality of life in addressing these disparities. The aims of this study were to conduct a systematic review of the literature about teaching cultural competence in dental education and to explore the particular relevance of that teaching for the oral health care of Indigenous populations in Australia. A systematic review employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was conducted of published studies that explored cultural competency interventions in dental curricula. A total of 258 studies from 2004 to 2015 were identified; after removing duplications and applying criteria for exclusion, 12 were selected for analysis, involving 1,360 participants. The principal themes identified in the qualitative analysis of these studies were curriculum content, curriculum delivery, community service-learning, reflective writing, and evaluation. Students need knowledge of health disparities and community health to better understand the perspectives of culturally diverse populations and to communicate effectively with people from various cultures. The principal strategies that improved cultural competence in the articles examined in this study were educational seminars, community service-learning, and reflective writing. These findings suggest that integration of cultural competency curricula using a combination of didactic or online training, community engagement, and reflective writing may increase the cultural knowledge and skills of dental students.

Financial Stress and Indigenous Australians

We examine the high levels of financial stress among Indigenous populations in Australia. We estimate separate models for the determinants of financial stress for Indigenous and non-Indigenous households and show the importance of separately considering Indigenous disadvantage. We use these models to build equivalence scales for both groups. We find evidence consistent with financial stress being exacerbated by demand-sharing (“humbugging”). The evidence also suggests that financial stress is reduced by engagement in traditional hunting and gathering activities.

Healthcare utilization for arthritis by indigenous populations of Australia, Canada, New Zealand, and the United States: A systematic review☆.

Indigenous populations of Australia, Canada, New Zealand, and the United States of America (USA) experience a higher prevalence of arthritis conditions. Differences in clinical outcomes and mortality may reflect healthcare service use inequities. The objective of this study was to summarize healthcare service use patterns described in the existing literature in order to identify gaps and inform strategies to limit the pronounced negative impact of arthritis on Indigenous populations. Medline, EMBASE, CINAHL, and Indigenous-specific electronic databases (to June 2015) were used to identify cohort, case-control and cross-sectional studies describing healthcare service use by Indigenous populations with specified inflammatory arthritis, osteoarthritis, or rheumatic disease conditions. We extracted information on the study setting and methodology, primary outcome and assessed study quality, and risk of bias. In total, 19 studies were identified describing three types of healthcare service use: physician visits, hospitalizations, and surgeries. In Canada and New Zealand, Indigenous populations had 36-51% fewer visits to specialists than the non-Indigenous population. Indigenous populations in Canada, New Zealand, and the USA had 37-300% more hospitalizations due to arthritis complications than the non-Indigenous population. Indigenous populations in Australia, Canada, and New Zealand had 27-85% fewer arthroplasties for osteoarthritis than the non-Indigenous population. Indigenous populations had higher hospitalization rates but lower use of specialized services for arthritis conditions. Strategies to improve access to specialized arthritis services might reduce health outcome inequities.

Pining for the fjords1

Pining for the fjords¹

Identification change and its effect on projections of the Aboriginal and Torres Strait Islander population in Australia

Since the 1971 Census, the Australian Aboriginal and Torres Strait Islander (Indigenous) population has grown faster than predicted by births, deaths and migration. An important and likely source of this unexplained growth is identification change, where a person changes how they identify or are identified by the household between one census and the next. In this paper, we use the Australian Census Longitudinal Dataset to detect identification change between 2006 and 2011 and include this information in a multistate population projection model. The projection model is applied to Australia, New South Wales and the Northern Territory over the period 2011–2061. The results indicate that identification change, particularly in the youngest age groups (0–9 years), had a positive impact on Indigenous population growth between 2006 and 2011. The projected Indigenous population initially grows faster than otherwise due to a net increase in people identifying as Indigenous, but slows as it interacts with the slow-growing non-Indigenous population. The results also suggest that the way in which identification change is modelled substantially affects projected trajectories, particularly in areas where identification change is substantial. While demographic modelling would benefit from further multidisciplinary research on the drivers and populations at risk of Indigenous status change, this study underscores the importance of incorporating identification change to improve projections of the Indigenous population in Australia.

001.6 Exploring the benefits of molecular testing for gonorrhoea antibiotic resistance surveillance in remote settings

Background The latest nucleic acid amplification tests (NAAT) for gonorrhoea are convenient and accurate, and are often used in place of culture-based tests for diagnosis. However the increasing use of NAATs in remote settings in Australia has compromised surveillance for gonorrhoea antimicrobial resistance (AMR). A molecular resistance test that can make use of samples collected for NAAT diagnosis may provide a means to enhance surveillance in remote settings where the availability of samples suitable for culture-based AMR testing is declining. We used a mathematical model to assess the potential benefit of a molecular test in terms of the timeliness of detection of gonorrhoea AMR. Methods An individual-based mathematical model was developed to describe the transmission of gonorrhoea in a remote Indigenous population in Australia. We estimated the impact of the molecular test on the time delay between first importation and the first confirmation that the prevalence of gonorrhoea AMR has breached the WHO-recommended 5% threshold (when a change in antibiotic should occur). Results The model suggests that when culture is the only means of testing for AMR, the breach will only be detected when the actual prevalence of AMR in the population has already reached 8 – 18%. With the addition of a molecular AMR test and assuming AMR can be determined for all samples, the breach will be detected when the actual prevalence of AMR in the population has reached 6%, which only slightly exceeds the recommended notification threshold of 5%. Conclusion Molecular tests have the potential to provide more timely warning of the emergence of gonorrhoea AMR in remote settings where surveillance is compromised by the increased use of NAATs for diagnosis. This in turn will facilitate earlier treatment switching and more targeted treatment, which has the potential to reduce the population impact of gonorrhoea AMR. Disclosure of interest statement This work was supported by National Health and Medical Research Council Project Grants (APP1025517). The National Neisseria Network is funded by the Australian Government Department of Health. The Kirby Institute is funded by the Australian Government Department of Health and Ageing and is affiliated with the Faculty of Medicine, University of New South Wales. The views expressed in this publication do not necessarily represent the position of the Australian Government.

Atrial fibrillation in the Indigenous populations of Australia, Canada, New Zealand, and the United States: a systematic scoping review.

BackgroundThe epidemiology of atrial fibrillation (AF) among Indigenous minorities in affluent countries is poorly delineated, despite the high cardiovascular disease burden in these populations. We undertook a systematic scoping review examining the epidemiology of AF in the Indigenous populations of Australia, Canada, New Zealand (NZ) and the United States (US).MethodsPubMed, Scopus, EMBASE and CINAHL-Plus databases were systematically searched in May 2014. Supplementary full-text searches of Google Scholar and government website searches were also undertaken.ResultsKey findings from 27 publications with diverse aims and methods were included. Small studies from Canada and NZ suggest higher AF prevalence in Indigenous than other populations. However, this was not reflected in a large sample of US male military veterans. No data were identified on community-based incidence rates of AF in Indigenous populations. Australian and Canadian studies indicate higher first-ever and overall AF hospitalisation rates among Indigenous than other populations, at younger ages and with more comorbidity. Studies in stroke, heart failure and other clinical groups demonstrate AF as a common comorbidity, with AF possibly more prevalent at younger ages in Indigenous people. Indigenous patients have similar early post-hospitalisation adjusted mortality but higher 1-year risk-adjusted mortality than non-Indigenous patients.ConclusionsNo clear epidemiological pattern of AF frequency across the considered Indigenous populations emerges from the limited available evidence. AF should be included in key conditions reported in national surveillance reports, although Indigenous identifiers are required in administrative data from Canada and the US. Sufficiently powered, community-based studies of AF epidemiology in diverse Indigenous populations are needed.Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-015-0081-6) contains supplementary material, which is available to authorized users.

Exploring the Benefits of Molecular Testing for Gonorrhoea Antibiotic Resistance Surveillance in Remote Settings.

BackgroundSurveillance for gonorrhoea antimicrobial resistance (AMR) is compromised by a move away from culture-based testing in favour of more convenient nucleic acid amplification test (NAAT) tests. We assessed the potential benefit of a molecular resistance test in terms of the timeliness of detection of gonorrhoea AMR.Methods and FindingsAn individual-based mathematical model was developed to describe the transmission of gonorrhoea in a remote Indigenous population in Australia. We estimated the impact of the molecular test on the time delay between first importation and the first confirmation that the prevalence of gonorrhoea AMR (resistance proportion) has breached the WHO-recommended 5% threshold (when a change in antibiotic should occur). In the remote setting evaluated in this study, the model predicts that when culture is the only available means of testing for AMR, the breach will only be detected when the actual prevalence of AMR in the population has already reached 8 – 18%, with an associated delay of ~43 – 69 months between first importation and detection. With the addition of a molecular resistance test, the number of samples for which AMR can be determined increases facilitating earlier detection at a lower resistance proportion. For the best case scenario, where AMR can be determined for all diagnostic samples, the alert would be triggered at least 8 months earlier than using culture alone and the resistance proportion will have only slightly exceeded the 5% notification threshold.ConclusionsMolecular tests have the potential to provide more timely warning of the emergence of gonorrhoea AMR. This in turn will facilitate earlier treatment switching and more targeted treatment, which has the potential to reduce the population impact of gonorrhoea AMR.

Primary health-care responses to methamphetamine use in Australian Indigenous communities.

Crystal methamphetamine (commonly known as 'ice') use is currently a deeply concerning problem for some Australian Indigenous peoples and can cause serious harms to individual, families and communities. This paper is intended to support best practice responses by primary health-care staff working with Australian Indigenous people who use methamphetamine. It draws on a systematic search of relevant databases to identify literature from January 1999 to February 2014, providing an overview of prevalence, treatment, education and harm reduction, and community responses. The prevalence of methamphetamine use is higher in Indigenous than non-Indigenous communities, particularly in urban and regional settings. No evidence was identified that specifically related to effective treatment and treatment outcomes for Indigenous Australians experiencing methamphetamine dependence or problematic use. While studies involving methamphetamine users in the mainstream population suggest that psychological and residential treatments show short-term promise, longer-term outcomes are less clear. Community-driven interventions involving Indigenous populations in Australia and internationally appear to have a high level of community acceptability; however, outcomes in terms of methamphetamine use are rarely evaluated. Improved national data on prevalence of methamphetamine use among Indigenous people and levels of treatment access would support service planning. We argue for the importance of a strength-based approach to addressing methamphetamine use, to counteract the stigma and despair that frequently accompanies it.

A case of severe Acute Rheumatic Carditis in an Indigenous Australian boy

He presented initially with fever, sore knee and lower back pain. Later he developed Pleuritic chest pain & respiratory distress, treated with IV antibiotics. He developed Haemoptysis, shock, AKI and a pansystolic murmur. CXR showed signs of heart failure. A provisional diagnosis of infective endocarditis was made. TTE showed a small pericardial effusion, severe Mitral and moderate Aortic incompetence. TOE excluded valvular vegetations. A provisional diagnosis of Acute Rheumatic Carditis was made. Literature search of societies guidelines and health search engine was done to help guide evidence-based treatment. Opinion from experts at Darwin hospital was also sought. Either there was no clear evidence-based treatment for a severe case like that or the evidence was based on very old, non-randomised data. An initial trial with high dose Aspirin, corticosteroids and standard heart failure treatment was undertaken. Clinically cardiac and renal function deteriorated. Patient underwent cardiac surgery. Intra-operative findings were of severe pericarditis and prolapsing NCC of Aortic valve. Mitral leaflets were tethered and thickened with enrolled edges. Mitral and Aortic valves were replaced with mechanical valves. Histopathology confirmed rheumatic heart disease. Conclusion: This case represents a severe form of acute rheumatic fever, a disease still common in the indigenous population of Australia. Traditional medical management employed in the mild forms of the disease is ineffective in severe cases and requires tertiary surgical care.