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Vol 23 Number 1 2013 Fiji Medical Journal Instructions to Authors Foreword byFiji National University Vice Chancellor Dr Ganesh Chand Foreword by Fiji Medical Association President Dr. James Fong 9 Evaluation & Assessment of Diabetes Knowledge Among Trainee Teachers Alka Sewram 10-13 Original ResearchSome common barriers to self-care amongst Type 2 diabetic patients in Sigatoka medical area Dr. Sravaniya Dasi PerspectiveClinician to Health Manager - The Transition Dr Neel Nitesh 17-20 Case ReportPlasmablastic lymphoma in AIDS:Case Report and review of literature Dr. Iane Panjueli 20-23 Hypereosinophilic Syndrome: A rare differential diagnosis for profound leucocytosis Dr. Dipesh Raniga CommentaryOperational Research capacity building in Fiji Francis X. Hezel Eulogy: Late Dr Umanand Prasad, the philanthropist

Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal Information about FMJ
Dr. Kamal Kishore The FMJ is a journal for clinical practitioners in the country and the region, with wide membership of International advisory board
the association. It aims to publish three times yearly. The main aim of FMJ is to provide a platform for Prof Wilfred Peh MBBS (S'pore), MD (Hong Kong), DMRD (London), FRCP (Glasg), FRCP (Edin), FRCR an exchange of knowledge, experiences and opinions on all aspects of health among the health care (UK), MHSM (Sydney) professionals. It contains peer reviewed original papers, case reports, communications, viewpoints and Immediate past Editor Singapore Medical Journal opinions, reviews, and news. Head of Department, Senior ConsultantKhoo Teck Puat Hospital Instructions to Authors
Fiji Medical Journal is a peer-reviewed joint publication of Fiji National University & Fiji Medical Asso- A/ Prof Joan Faoagali ciation. It aims to publish scholarly articles from contributions from its members and others in the health care field. It invites contributions in the form of: Adjunct Associate ProfessorUniversity of Queensland Original articles • Brief communications and case reports Prof Peter L Munk MD, CM, FRCPC, FSIR Editor, Canadian Association of Radiologists Journal Viewpoints and perspectives Professor & Head, Musculoskeletal Division Department of Radiology Book reviews, and Vancouver General Hospital Organizational news and information University of British ColumbiaCanada Expression of interest is also invited from experts in major disciplines to serve on the editorial board. While key membership of the board would comprise representatives in major fields such as medicine, surgery, pediatrics, pathology, public health etc., accomplished scholars in other fields with an interest in Jose F. Lapena Jr. M.A., M.D., FPCSProfessor of Otorhinolaryngology, University of the Philippines Manila human health and willingness to contribute towards the journal's mission would also be considered. University Scientist II, University of the Philippines SystemEditor, Philipp J Otolaryngol Head Neck Surg Please forward all submissions to: President, Philippine Association of Medical Journal Editors (PAMJE) Editor Fiji Medical Journal Secretary-General, Asia Pacific Association of Medical Journal Editors (APAME) Dr Tomasz KiedrzynskiPrincipal AdvisorCommunicable DiseasesPublic HealthClinical LeadershipProtection & RegulationMinistry of HealthNew Zealand Editorial board
Dr. James Fong
A/Prof Pon Swamy Goundar
Dr. Aneley Getahun
Keshwa N. Krishna
A/Prof Dan Orcherton
Dr. Gyaneshwar Rao
Saubhag Balgovind
Dr. Reapi Mataika
Dr. Myrielle Allen
Dr. Mark Cumberbatch
Prof Rajanishwar Gyaneshwar
Dr Margaret Cornelius

Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal The Title Page.
FMJ invites submissions of original papers and reviews on all aspects of health. Any health worker who Should include the titles, full names of all authors, and names, addresses and contact number (including actively participates in the process of providing medical education, medical care and primary care services email addresses) of institutions where the work has been done so that the author can be contacted. If more should consider contributing to this Journal.
than one author, indicate the author to whom correspondence should be directed.
The views and opinions expressed in the Journal do not necessarily reflect those of the editorial staff, Advi-sory Board or sponsoring agencies. Manuscripts are accepted for publication only with the understanding that they have not been published or submitted for publication elsewhere. Priority will be given to articles References should be Arabic numbers in closed brackets at the end of the sentence. They should be and subjects relevant to health and health practices in the Pacific. All manuscripts will be peer reviewed kept to a minimum and must be in the Vancouver style.
before being accepted for publication.
Types of Contributions
Each original article should include an informative Abstract; Introduction; Patients, Materials and Methods; The types of contributions are as below but other types of contributions may be accepted for publication Results; Discussion; and References.
at the Editor's discretion.
Abbreviations and Units.
Only standard abbreviations and units should be used.
Comments from the editors on the contents and issues covered by the Journal. Invited editorials may be published in line with themed issues or on topics of current relevance. Generic names should be used for all pharmaceuticals mentioned.
Original Articles:
Reports of original and new investigations or contributions. Text preferably to be a maximum of 3000 • Tables, Photographs, Charts and Other Artwork Brief Communications and Case Reports:
Contents similar to that of original articles but text should be no more than 1500 words. These may Tables are best done using the "Table" features of your word processor. If tables are prepared from include articles on various aspects of health, such as current health issue at regional or international level, a spreadsheet, please include the original speadsheet file(s). All tables must have a heading and may services, awareness, etc.
include footnotes that make it understandable without reference to the text. All tables will be re-formatted to our house style by our editorial staff.
Critical analysis of previously collected and published information. Text to be a maximum of 3000 words. Ideally such articles would come from contributors who command an authority on the subject. Photographs should be clear glossy prints, preferably mono (black & white). The article title, author(s) and notes on the photo should be written on the back.
Viewpoints and Perspectives:
These are informed comments or papers on health issues. Text to be no more than 4000 words.
Charts and Figures:
Charts and figures (an original with two copies of each) should be prepared on separate pages. If computer generated, indicate which program (including version number) produced them and submit the Short reports of clinical experience, topics of interest, or comments on previous articles. Text to be no file(s) separately on a PC formatted disk. Preferred software is Microsoft Excel and vector art software. For more than 500 words.
figures prepared from a spreadsheet, please include the original spreadsheet file(s).
Book Reviews:
The journal reserves the right to edit all the articles received. No reproduction of any part of the journal These are informed reviews of no more than 1500 words of books pertinent to health.
is permitted without prior written consent of the editor. Organizational News, Information:
These will be brief announcements about regional organizations' activities, news and information.
Information on Manuscripts
Manuscript should be in English.
Typed and handwritten manuscripts.
Submit all typing in double-spaced times new roman font 12. Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal Publish or (flourish?) perish
the benefits of a vegetarian diet in reducing mortality data in formulating policies to address health challenges, is being introduced in Fiji and in the Pacific due to cardiovascular, and endocrine (including through a Fiji National University initiative with its partners. A commentary on this concept is included in The Fiji Medical Journal's first issue of the year In India, where the population is largely vegetarian, On a less academic note, there is a review of the book on activism by Darlene Keju, a woman survivor is in your hands. After a hiatus of nearly three while the incidence of diabetes is on the rise, the of nuclear testing on Marshall Islands atoll. The book, titled ‘Don't ever Whisper', has been reviewed by years, the Journal has been revived thanks to the complications related to its poor management Francis X. Hezel. efforts of Dr. Ganesh Chand, the Vice Chancellor such as End Stage Kidney Disease (ESKD) and Until the next issue, and in the hope of the receiving more articles for publication.
of the Fiji National University (FNU). Through the amputations are seen in much smaller numbers, active support and cooperation of Dr. James Fong, perhaps reflecting a benefit similar to the findings Dr. Kamal Kishore President of the Fiji Medical Association (FMA), the of the Adventist study. Journal is now jointly published by FMA and FNU. Diabetes is truly a global phenomenon with Much like the history of medical education in the rise in its incidence in every socio-economic Fiji, the history of medical publication in Fiji also group of practically every country in the world, reaches a long way back. One of the earliest albeit at variable rates. And the costs related to 1. Journal of Native Medical Practitioners 1949 vol 4 (2) available copies of the Journal is the 1949 issue its management are simply shocking. A United 2. Fiji Medical Journal 1961.
of the Journal of Assistant Medical Practitioners, Kingdom diabetes group estimates that for Great 3. Journal of Fiji School of Medicine 1969 vol IV (8) which actually replaced the then existing journal of Britain, the NHS spends over 25 million GB pounds 4. Orlich MJ, Singh PN, Sabaté J, Jaceldo-Siegl K, Fan J, Knutsen S, Beeson WL, Fraser GE. Vegetarian native medical practitioners! 1. The first recorded per day on diabetes care.5
dietary patterns and mortality in Adventist Health Study 2. JAMA Intern Med. 2013 Jul 8;173(13):1230-8 issue of the Fiji Medical Journal came out in 1961.2. Two studies conducted recently in Fiji on this 5. Diabetes in the UK 2010: Key Statistics on Diabetes, Diabetes UK, March 2010 Just like the Fiji School of Medicine, the journal also subject, are published in this issue. The first one
changed hands and names through its journey, and analyses the reported barriers to self-care and
for some time, was published as the Fiji School adequate management of diabetes among patients
of Medicine Journal.3. All these publications were at the sub-divisional hospital of Sigatoka. The other
initiated by locally trained practitioners, when these paper by an academic of the Umanand Prasad
journals were little more than a few pages of hand School of Medicine in Lautoka reports the level of
typed, cyclostyled and stapled brown paper sheets. awareness about diabetes among school teachers,
Despite this goodwill, throughout its history, the Fiji and their potential role in diabetes prevention Medical Journal has faced the perennial challenge education. These articles bring home two significant of a lack of articles from its readership. Time has points: research is not complete unless it is shared moved on, the Journal's readership has grown, as through publication, and, that important research have academia and research in the country, but can be conducted in any setting, even with very this lack of interest among its readers to publish, limited resources. has remained a serious hindrance to the Journal's Another equally important health issue – HIV - publication. This attitude is likely to prevail until is again in focus. We publish a case report in this incentives, as well as a requirement to publish, are issue, on plasmablastic lymphoma, an unusual put in place. The focus of this first issue of 2013 cancer due to HIV infection. Another interesting reflects the greatest health challenge faced by the report of a case of Hypereosinophilic Syndrome is country and the region, and indeed by the world. also published in this issue. The scourge of diabetes, causing havoc on the Fiji recently witnessed the loss of a clinician who state of human health, has caught the attention of through his personal motivation and resources researchers and clinicians alike. As different regions initiated medical education training at a private of the world face this challenge in their own settings, institution in the country. The sudden passing some peculiarities of disease behavior are slowly away of Dr. Umanand Prasad, founding Dean of coming into full view. Some of these peculiarities the School of Medicine named after him, left his include drastic weight loss and the starving of self. students, friends and colleagues in a state of shock On the positive side of things, efforts towards and disbelief. A tribute to his contribution to the reducing or even eliminating diabetes, such as cause of medical training in Fiji, has been written by lifestyle changes and the drive to engage in some Mrs. Alka Sewram, an academic of the Umanand kind of daily physical activity, are all producing more Prasad School of Medicine. pronounced results. In a recent paper based on an Operational research, a long-established tool in Adventist health study, the authors have reported western countries, and which makes use of available Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal Foreword by Fiji National University Vice Chancellor, Dr Ganesh Chand
Foreword by Fiji Medical Association President, Dr. James Fong
For members of an intellectual fraternity, there can be nothing better than a journal that can act as a platform where they can write and publish, share their latest findings, research and data, and read the writings of others on any range of issues. It is with great pleasure that I welcome you all to the readership network of the Fiji Medical Journal. It has been a while since we have been able to publish a journal and the Fiji Medical Association is very grateful Be it current topics of interest, latest developments, research outcomes, or just regular updates, journals, for the intervention of the Vice Chancellor of the Fiji National University to support the ongoing production by virtue of their professionally collective and summative nature, become portals of continuing education of the Fiji Medical Journal. The FMA Journal now represents a partnership of two organizations that have in every discipline. The Fiji Medical Journal has always aimed to serve the same purpose for its reader- a long and rich history in the evolution of medical education and practice in Fiji. In the more recent decade, the demands on the practice of medicine in Fiji have increased exponentially. The medical system has responded by making efforts to provide higher quality routine services and new, higher end services. This Peer reviewed articles based on sound research, issues affecting the health of local populations, devel- has set more demands from us to get more gains from a relatively diminishing resource base. The need for opments in the field of medicine, or the current state of health care services, are all topics of interest that research and publications to inform professionals on how to work smarter has never been more intense. its readership should be aware of. The Journal serves the dual purpose of enhancing the knowledge of In this regard the objectives of the FNU College of Medicine, Nursing and Health Sciences and the Fiji its readers as well as providing them with a venue for sharing their articles with their peers. Medical Association are complimentary in the efforts to sustain high levels of professionalism in the practice of medicine, despite broadening demands. The FMA is very hopeful that this joint partnership venture will With a readership base of all registered medical professionals in the country and in the region, this Jour- help to increase the capacity for medical professionals in Fiji to better understand the environment they nal has a wide reach for the purpose of dissemination of knowledge. work in and to better respond to patient needs. We noted the Fiji Medical Journal had been in a state of hiatus for almost two years. The Fiji National University as the only institution in the delivery of healthcare training in Fiji and the Pacific, saw it as its responsibility to revive this important publication, something it aims to do for publications in a similar state in other areas. As a result of our discussions with the Fiji Medical Association, which has been the custodian of the Jour- nal, we have jointly agreed to jointly publish the journal from 2013. The first issue in this regard is in your hands.
Writing and communicating research, least of all in a field like medicine, is a skill that we need to nurture in Fiji and the Pacific. Reputations of academic journals emerge from the rigorous process of peer review and scrutiny. The FMJ aims to be one such reputable journal; articles published in the Journal are peer reviewed and follow the best practices in academia in this regard. I commend the FMJ to you.
Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal Evaluation & Assessment of Diabetes
and the community sector (key stakeholders). It is well-known that children are innocent, open with brief details on diabetes and its compli- Knowledge Among Trainee Teachers
Diabetes, if not controlled, can lead to major com- to new teachings, and adopt concepts religiously cations. plications namely, Retinopathy (resulting in blind- as gospel. If school children are taught awareness Senior Lecturer Pharmacology ness), Nephropathy (resulting in kidney failure), about diabetes in the simplest way, about the dan- Umanand Prasad School of Medicine (UPSM), Neuropathy, and Cardiopathy (resulting in heart gers of the disease and the dangers of unhealthy The data from the questionnaire was collected and University of Fiji, Saweni, Lautoka diseases, heart attacks).
eating and unhealthy lifestyles, they can be Fiji's analysed as follows: Address for correspondence: [email protected] Yet, prevention, both primary and secondary is pioneer advocators for healthy living. They in turn, possible. Good glycaemic control is the key for can teach, guide and encourage their parents and Population: 462
secondary prevention combined with adjustment of family to adopt a healthy lifestyle and have an over- Diabetes, one of the Non Communicable Diseases lifestyle factors to enable the patient to still have a all positive healthy influence5.
Sample size: 400
(NCD), is rising dangerously in the Pacific region in- good quality of life. Fiji will then gradually see a decline in the preva- cluding Fiji, reflecting all races and both young and Primary prevention should be the focus. lence of diabetes with added positive influence on Sample Target: Trainee teachers at FNU Trainee
old. Diabetes is essentially a chronic lifestyle dis- Type II Diabetes is not only a serious disease; it is related diseases such as heart diseases, a decline College at Natabua ease contributed by multiple lifestyle factors which common, costly, yet controllable and preventable. in diabetes complications and eventually a reduced Age Group: 18-30
are mostly modifiable in order to not only control The public needs to be empowered to move from health bill for the government.
diabetes well and avoid or delay it's complications diabetes awareness to adoption of actual lifestyle Primary school teachers are the first point of con- Ethnicity: Mixed (ITaukei, Indo-Fijians, other
but also to prevent it in the first place1,2,3.
changes to help prevent the disease.
tact to young children when it comes to education. races) The UN NCD summit - the International Diabetes A common and effective strategy for health pro- These teachers can act as the best instruments Gender: Mixed
Federation (IDF) - met in September 2011 for the motion is health education - disease prevention and through which to relay the health message to young 66th session.
improving health. minds in primary schools.
A total of 24 questions were listed in the question- In Fiji, with newer trends of western foods and life- So then, the question becomes whether the teach- naire. Below are the highlights. a. Acknowledged that the global burden and threat style, growing numbers of Fijians are facing major
ers themselves are well-informed and well-educat- 1. The aim was to determine their level of under-
of Non-Communicable Disease constitutes one NCDs especially diabetes and heart diseases. Ac- ed about diabetes and its health consequences. standing of diabetes.
of the major health challenges.
cording to WHO, 1998, Fijians are far more likely to Would they themselves have full awareness and 85% identified diabetes correctly Recognised the primary role and responsibility suffer from diabetes and obesity than Australians. understanding (in layman's terms) of diabetes in or- 5 % identified diabetes as an infectious disease of governments in responding to the challenges Steps 2 survey has revealed that 1 in 3 people in der to effectively and clearly relay the message? 5-10% identified diabetes as a disease affect of NCDs and the essential need for the efforts Fiji have diabetes with more indigenous Fijians be- ing the heart.
and engagement of all sectors of society to ing diagnosed every year. Statistics show that more To assess knowledge levels among secon- 2. The aim was to test their understanding and
generate effective response for the prevention amputations are carried out on I-taukei diabetes dary school teachers on diabetes and whe- identification of symptoms of diabetes. Out of and control of NCDs4.
patients than Indo-Fijian patients. The cost of life- ther they are able to teach their students.
symptoms listed: c. Note with profound concern that, according to style diseases is high for any community in any giv-
b. To submit the research report to the Ministry of 10% identified 4 symptoms
WHO in 2008, an estimated 36 million of the en country. Diabetes prevention is proven, possible Health, Fiji to enable them to take appropriate 10% identified 3 symptoms 57 million global deaths (63%) were due to and powerful. steps in the field of education and awareness 10% identified 2 symptoms NCDs, principally cardiovascular disease, of diabetes.
70% identified only 1 cancers, diabetes and chronic respiratory Diabetes in Fiji:
3. The respondents were asked that in their opin-
On average, relevant knowledge of diabetes is The long term aim was to target the trainee ion, how common was diabetes in Fiji? d. The latest figures from International Diabetes poor among the general population. They are not
teachers so that they gain knowledge and 90% identified it as very common.
Federation (IDF) reveal that currently, 366 fully aware of what it is, what causes diabetes, cause awareness of diabetes in the commu- 5-10% identified it as somewhat common or million people have diabetes globally, 4.6 million what risk factors are involved, how to manage dia- nity, so that they, in turn, can educate and not aware. deaths are due to Diabetes and US$465 billion betes once they have it, how it can affect them and disburse knowledge accurately to their students. is spent on care for Diabetes.
their family, and the consequences of the illness. 4. The respondents were asked if diabetes could
e. Note also with profound concern that NCDs are People in Fiji are not treating diabetes as a seri-
affect them.
among the leading causes of preventable ous illness. Treating and managing diabetes is an a. A total number of 400 trainee teachers were
80% said ‘Yes' morbidity and of related disability. important area for all doctors. However, WHO and identified and interviewed and given 5% said ‘No' f. Recognise that prevention must be the corner health educators cannot overemphasize on the pre-
a questionnaire to fill.
15% said ‘Maybe' stone of the global response and efforts to vention of diabetes. Not everyone is aware that b. The questionnaire was designed to test their
5. The respondents were asked about the risk
diabetes CAN be prevented. Prevention can come basic knowledge on diabetes; its symptoms, factors of contracting diabetes. Out of 6 risk g. Recognise that effective NCD prevention
about through simple education of the public to pro- complications, risk factors, and lifestyle mana- and control requires leadership and mote understanding and awareness, and the identi- 30% identified 5 out of 6 risk factors multi-sectoral approaches for health at both fication of the risk factors of diabetes in the general c. A Power Point presentation was held for all 30% identified 4
government (including health and education) trainee teachers on all aspects of diabetes. 20% identified 3
d. Pamphlets were distributed to the respondents, 20% identified 2
Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal Obesity and diet/eating habits were identified group thought they possessed good knowledge raise proper awareness and it is highly recommend- 13.NDEP; National Diabetes Education Program by most targets.
about diabetes. Most identified it as a lifestyle dis- ed that diabetes education be officially included in Strategic plan 2008- 2010. NDEP_Diabetes In- 6. The respondents were asked if they knew
ease, that it is very common in Fiji, and were aware the curriculum for Fiji students in high schools. formation, Educa-tion and Treatment. http//ndep. whether diabetes can be prevented.
that it can be a serious disease. Most also identified 60% identified ‘yes' it as affecting older adults and that it could affect 14. History of Diabetes; Canadian Diabetic 20% identified ‘no' 1.Dr Richard et al, improving Diabetes awareness, Association; 26th Oct 2011 http://chinese- 20% identified ‘maybe' school,netfirms.com/diabetes-history html.
However, they possessed a poor knowledge of education and disease management among pa tients at the Anthony L Jordan Health Centre, Oct 7. The respondents were asked if they were
presenting symptoms of diabetes, the type of diabe- aware of any complications of diabetes.
tes or its complications. Most were able to identify 2. IDF Factsheet 1: Diabetes Prevention 20% identified ‘yes' an immediate family member, friend, colleague, or Some common barriers to self-care amongst
80% identified ‘no' 3. David Marrero, Professor of Medicine, Endo Type 2 diabetic patients in
friend's family member as having the disease. Most crinology and Metabolism, USA; "Small Steps 8. The respondents were asked if they knew of
also identified some person(s) they had known to Sigatoka medical area
Big Rewards -Your game plan to prevent Type 2 any person(s) who had limb (leg/toe) amputa- have had limb (leg/toe) amputations in Fiji.
Dr Sravaniya Dasi Diabetes" ; Oct 2011 www.ndep.nih.gov Sub-Divisonal Medical Officer Nadroga/Navosa Although the respondents identified diabetes as 4. President of the General assembly, 66th 90% said ‘yes' a lifestyle disease, with the majority stating that Fiji Ministry of Health Session, " Political declaration of the High-Level 10% said ‘no' health was very important to them and that diabe- Meeting ofthe General assembly on the preven Address for correspondence: [email protected] 9. The respondents were asked if they were
tes is preventable, only 70 % felt that obesity was tion and Control of Non Communicable Disea- aware of the role of the following factors in the related and only 40-50% felt that physical inactiv- ses, 16th Sept 2011, www.un.org/en/ga/66/ Diabetes is adversely affecting the lives of Pacific incidence of diabetes? ity or eating habits were related to the incidence of meetings/5.K. Khunti, M.A. Stone, J.Bankart, a. Obesity: 70% identified ‘yes'
diabetes. Interestingly enough, though, the majority P.Sinfield, A. Pancholi, S. Walker, D. Talbot, A. inhabitants. Early onset, complications of diabetes, 10% identified ‘no' believed that nutrition and healthy eating in children Farooqi, M.J.Davies; Primary Prevention of and poor compliance leading to inadequate 20% identified ‘maybe' at an early age was very important. Accordingly, Type 2 Diabetes and Heart Disease: action re management of those with diabetes, is enormously search in secondary schools serving an ethn- b. Physical inactivity:
40% identified ‘yes' they also strongly agreed on the possibility of in- costly to the ministry of health in terms of resources 50% identified ‘no' ical ly diverse UK population, Nov 27, 2007; tervention to educate and increase awareness of & health care workers' time. At the same time, it 10% identified ‘maybe' diabetes in these children. Therefore, the majority is affecting productivity of the work force, leading c. Eating habits: 40% identified ‘yes'
(95%) strongly agreed on teaching school children to a breakdown in family support and daily lives at 6. Geraldine Panapasa, July 1st, 2008; Fiji Times 20% identified ‘no' about diabetes as part of the school curriculum, if every level. This study aims to explore some of the Online,"The inside story on Diabetes" 40% identified ‘maybe' the education department were to approve of such. reasons for poor compliance and self-care among 10. The respondents were asked as to how impor- It is seen that the need is there, firstly to clarify the attendees at the Sigatoka health center. 7. Research paper on Diabetes Mellitus. tant nutrition and healthy eating was in children knowledge about diabetes in these trainee teach- http://www.echeat.com/essay.php?t=27503, Key words: Diabetes, Fiji, barriers to self-care, at an early age? ers (aged 18-30), its symptoms, complications, and 95% identified ‘very important' risk factors.
8. Prevalence and Awareness regarding Diabetes 5% identified ‘important' While they believe that diabetes is preventable, Mellitus in rural Tamaka. http://www.research 11. The respondents were asked if they agreed they need to be taught how diabetes can be pre- Diabetes is a chronic disease which has severe that school children represent ‘good targets' vented. The awareness of NCD risk factors needs to 9. IANS; UAE launches awareness campaign in complications resulting in multi-organ failure, if in the intervention of educating and increasing be deepened and strengthened. Once this younger schools, April 14th 2010 http://blog.targana.com/ not controlled. The United Kingdom Prospective awareness of diabetes at an early age? group of teachers fully understand these NCD risk Diabetes Study Group (UKPDS) results establish 10. DenizCaliskan, OyaOzdemir, EsinOcaktan, 85% strongly agreed factors, they will not only be effective in prevention that retinopathy, nephropathy, and possibly 12% agreed AysunIdil; "Evaluation of awareness of Diabetes neuropathy are benefitted by lowering blood glucose themselves from contracting diabetes (and other 3% didn't agree Mellitus and associated factors in four health NCDs) in later life, but will also be able to effec- levels in type 2 diabetes with intensive therapy, 12. The respondents were finally asked on their centre areas"; Patient Education and tively and strongly drive the message (of preventing which achieved a median HbA1c of 7.0% compared Counseling, July 2006; vol 62, issue1, pages contribution to the community as future NCDs) to young school children. These school chil- with conventional therapy with a median HbA1c of 142-147. http//www.peccjournal.com/article/ school teachers. Therefore, if the education dren can in turn, drive home the message to their 7.9%. The overall microvascular complication rate department of Fiji were to approve of any mate families. This will not only increase the understand- was decreased by 25%1.
11.B.M Singh, J.J.W Prescott, R Guy, S Walford, M rial on diabetes as part of teaching Health Sci ing and awareness of diabetes but also possibly re- A 25 % reduction in complication rate is much Murphy, P.H.Wise; "Effects of advertising on ence, Basic Science or Biology, would they be sult in a new generation of adults, who, in their later awareness of symptoms of diabetes among gen appreciated especially in a country like the willing to be trained and then be willing to teach? years, will experience an overall lower incidence of eral public: the British Diabetic Association Fiji islands where tertiary management of the 95% identified ‘yes' diabetes and other NCDs. Study" . BMJ.1994; 308: 632 – 636 (5th March) complications of diabetes is not well established. 5% identified ‘maybe' There is an angiogram and coronary artery bypass 12. Promoting Good Health in Fiji – Case Study; unit which is available only in the main Specialist Interpretation of Data
In light of the literature review and the results, it is 26th May 2010 http://www.globaleducation.edna. Hospital, which requires overseas specialists It is seen that trainee teachers in the 18-30 age evident that diabetes education is very important to to periodically operate2. A haemodialysis unit is
Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal available but is very expensive as the Government gement7.
were not proactively and aggressively managing References
does not subsidise treatment costs for patients with • Based on the seven key areas of Diabetes self- glycemic controls. Three percent of these patients 1.UK Prospective Diabetes Stud Group: Intensive renal failure secondary to diabetes3.
care, a questionnaire was developed in the Siga- also mentioned that the doctor was not sending blood-glucose control with sulphonylureas or Therefore, it is critical for patients to prevent toka Medical area, where there is a population of them for blood tests. Managers from rural areas insulin compared with conventional treatment complications from diabetes by strict control of 56,000 and where the total registered number of in Fiji will find these results to be of value, as they and risk of complications in patients with type 2 diabetes. This is not going to be achieved solely by diabetes patients is 1,195 and the rate of preva- can advocate for more doctors who are committed diabetes (UKPDS 33). Lancet 352:837–853, relying on clinics for consultation where valuable but lence for diabetes is 5.2%. The questionnaire to diabetes care and give more time to patients. It 1998 very brief amounts of time are available for advise. focused on barriers in self-care in diabetes, for seems that health professionals need awareness 2. ANGIOGRAPHYFIJI. Available via website: Every three months, most health facilities in Fiji patients attending Sigatoka Health Centre. Thirty programs, so they can deliver quality care to http://angiofiji.com/(last accessed 30/6/13) offer clinical consultations free of charge to diabetic three patients attending diabetic clinics in Siga- patients. The current problem faced is that there can 3. Kidney Foundation of Fiji, Dialysis project. patients lasting an average of fifteen minutes. toka Health Centre were interviewed individually, be sometimes three doctors, and before attending Available via website: http://www.pacifichealth Medications are also provided free. Therefore for where the interviewer filled in the relevant respo- to the patients, the doctor has to do ward clinical voices.org/files/kidney%20 the majority of the time, the patient makes their own nses. The patients were asked to mention which duties, and starts the clinic at 11 am and ends at foundation%20of%20fiji%20dialysis%20project. hour by hour decision about what to eat, how much was the most important barrier to achieving 1 pm. In two hours they see up to 50 patients, that pdf (last accessed 30/6/13) to eat, how much insulin to eat, how to exercise good control of blood glucose, taking medications is approximately 5 minutes per patient. Rotation 4. Holt T, Kumar S. Support for people living with daily. Understanding the barriers that patients face and lifestyle advice8.
of duties has to be considered to increase doctor/ diabetes. ABC of diabetes, 6th Edition, 2010. in self care is an important component to delivery patient consultation times as well as spreading out Blackwell Publishing.
of service. Hence, clinicians need to encourage Results
the clinic in day and evening shifts so that doctors 5. Nagelkerk J, Reick K, Meengs L. Perceived patients in these brief consultation periods, about Results of this study are tabulated in table 1 can see some patients later. barriers and effective strategies to diabetes self care4.
Poverty is another barrier where patients cannot self-management. Journal seek medical attention due to lack of money.[9] This of Advanced Nursing 2006;54:151-158.
Materials & Method
can be addressed through social welfare officers. 6. Sigatoka statistics Available via website: http:// The area of study chosen is the Sigatoka Medical Most of the patients felt that they do not have family Fiji has a very good welfare system, where the under www.statsfiji.gov.fj/ (last accessed 30/6/13) area, a rural part of Fiji. Previous studies have support. This was in the case of those patients who privileged get a monthly allowance. Unfortunately, 7. American Association of Diabetes Educators. shown that stress can be a barrier in rural areas were widowed and who had to rely on other family patients do not know how to prioritize usage. For AADE7 self-care behaviours . The Diabetes Edu- as well as lack of awareness5. Rural areas in Fiji members for their subsistence. We have only two
example, Mrs G receives her allowance, but she cator, 34 (3) 2008, pp. 445–449 are renowned for three things: Rugby, Tourism and old age care facilities in the whole of Fiji, as the supports her family, as her daughter is divorced 8. Stetson B, Floyd J et al. Development and Agriculture,6 and it is a diverse group of people family network structure is very traditionally-based
and has four children, and she does not have any validation of The Personal Diabetes Question- whom we have to approach.
and favours extended family arrangements versus money left for her travel expense to the Clinic. The naire (PDQ): A measure of diabetes self-care There are seven key areas of self-management the nuclear family model, more so in rural areas.
family network needs to strengthened and one behaviors, perceptions and barriers. Diabetes for people with diabetes. It's important to under- The other significant barrier was stress in life, way of doing this is to introduce the participation Research and Clinical Practice Vol91,(3), stand and set goals for improvement in each area. which was 15%. Farming is a traditional occupation of a family member into a structured educational March 2011, Pages 321–332 These key areas are called the AADE7 Self-Care in rural areas in Fiji, and farmers have to leave for programme. This will assist the patient as the family 9. International Diabetes Federation Western Behaviours7. They are:
the farms at 5 am, and do not have time to take should be able to understand the needs of their Pacific Region. The World Health Organization 1. Healthy Eating - the patient learns to make hea- their medications. Another 12% cited physical family member with diabetes.
Regional Office for the Western Pacific.Sec- lthy food choices by paying attention to nutritional barriers such as amputation of lower limb, blindness retariat of the Pacific Community. Plan of action content and portion sizes.
or heart failure. The next barrier was expense of 2006–1010 for the Western Pacific Declara- 2. Being Active - Patient recognises the importance transportation costs to hospital and hospital costs. Through this small study, important self- barriers tion on Diabetes: from evidence to action. Availa- of physical activity and makes a plan to exercise The Nadroga/Navosa province has a vast land mass have been identified and strategies have been ble from: http://www.idf.org/webdata/docs/ in consultation with care givers. with rough terrains from Mango Bay Resort to Tau discussed as to how to assist patients overcome WPDD_PoA_2010.pdf (last accessed 13/7/13) 3. Monitoring - Learning to check and record blood on the Queen's Highway. Our coverage extends up these barriers. From these results, family support glucose levels.
into the highlands to Keiyasi and Kavanagasau and should be strengthened as it is one of the biggest 4. Medication - Patient remembers to take medica- into maritime Vatulele Island. Transport if available barriers to self-care for health care providers.This tions, and understands how they work.
is expensive.
study is important, as the management of any chronic 5. Gaining skills to identify problems or obsta- A major surprise was that as expected, not many illness depends on daily decisions which the patient cles to self-care behaviours and learning how to patients complained about the brief consultation can only take, only if they have been empowered5.
times where they did not receive much education When patients begin to have confidence that health 6. Reducing Risks - Understanding the potential and awareness. Health workers felt that they care providers understand their barriers, a major complications they are at risk for, and tak- were not spending much time with their patients; barrier, which is denial to seek help, falls down. ing steps to prevent them. however, the patients felt that they had enough time This was a small realization at the end of the study- 7. Healthy Coping - Developing healthy ways of in consultation. Another related barrier is that there which will forge a strong alliance between patient dealing with difficult times in your diabetes mana- is clinical inertia. Patients observed that doctors and health providers.
Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal Appendix Table 1: Patient Response
Barriers to Self Care
Clinician to Health Manager - The
of clinicians, such as professional autonomy, the Short time during clinics - doctor does not listen to my problems Transition
focus on individual patients, the desire for self-regu- lation, and the role of evidence based practice2.
Lack of family support systems for me, I have to eat what the rest of the Department of Public Health and Primary Care They then compare these values with those of family eats as I cannot cook College of Medicine, Nursing and Health Sciences managers: the emphasis on populations, the need Lack of awareness of disease on my part, I did not know that I could have Fiji National University for public accountability, the preoccupation with lost my foot and vision because of diabetes Address for correspondence: [email protected] systems and the allocation of resources. It can be Lack of seriousness of disease by provider - my sugar levels were always inferred that clinician and managers have vastly high but the doctor just keeps on writing same medications differing value sets. The structural frame of Bolman No perceived benefits of diabetes management - I never knew that I In today's dynamic health care industry many and Deal assumes that "organisations exist to could measure my sugars myself, and that there is a 25% reduction in clinicians make a transition to a health care achieve established goals and objectives"3. The set
complications if I did so manager's role. The reasons for the transition are of goals for a clinician will be different to that of a Lack of awareness of available resources. I did not know that there were varied however this transition is not an easy one manager and this is derived from the value held. reading materials as the role of a clinician and a manager varies According to Lawson in Harris and others, the main difficulty is trying to strike the right balance between Lack of reading skills on my part - I cannot read considerably. This paper will explore some of the difficulties and conflicts a clinician might face upon the welfare of the organisation as the utmost priority Stress in my life - I am a farmer, no time for myself making this transition and will explain the theoretical and the conditioning of clinicians to make the Lack of transportation to the doctor - Live far away, no time for checkups dimensions behind these conflicts using Bolman patient the utmost priority4. Alexander and others
Very social person, misses clinics due to social obligations and Deal's four frame model. The four frameworks and Thorne and others assert that most managers Expense of health care/medical visits that will be discussed are the: structural, political, who are clinicians have a clinical mindset and focus Denial and/or fear on my part human resource and symbolic frames. The structural on individual care rather than community care5,6.
Traditional therapy frame argues that by putting people in the right In order to be an effective health manager, a shift roles and relationships, formal arrangement can in commitment is necessary from individual care Other barrier- cannot exercise - amputation/ heart failure accommodate both collective goals and individual to care of the whole organisation. This essentially Side effects of medicine differences. According to the political frame, politics requires the manager to align with organisational Out of stock medications is the realistic process of making decisions and goals and focus on pursuing those goals. It may allocating resources in the context of scarcity and require a shift in loyalty as well.
divergent interests. The human resource frame centres on what organizations and people do to or Secondly, a new manager might face difficulties for one another. The symbolic frame focuses on settling in with a new role. A clinician normally how humans make sense of the chaotic, ambiguous works within one unit, has few colleagues or world in which they live. Meaning, belief and faith subordinates to handle. However when thrust are its central concerns. This paper will also touch into a senior management role, a manager's upon this transition in an organisational context and responsibility increases immensely. In addition to will try to explain the frameworks within which the allocating work to different units, a manager has transition will take place. In addition, suggestion to also coordinate and control all sections towards will be made as to how this transition can be made the overall organisational goals. Managers are successfully so the clinician-turned-manager will being increasingly given financial and budgetary have a positive impact.
responsibilities according to Braithwaite for which they are less than adequately prepared7. Bolman
and Deal assume that this fits into the structural Firstly, a clinician's value is aligned towards frame as "appropriate forms of coordination and individual patient care. Internal conflict arises when control are essential to ensure that individuals and
the clinician has to take up managerial duties units work together in the service of organisation
and organisational responsibility. Lawson states goals"3. A manager thus will be required to handle
that the transition from clinician to manager is "a several different people with competing needs and
change from a life of objective, scientifically based demands. At times the manager might have to
diagnosis and treatment of disease in individual resort to using authority to resolve issues and this
patients to a life of subjective, often manipulation of falls in the political frame. In addition, management
emotion-based group of people in an organisation"1. by nature is not structured in any way. It could be
Abbasi and others explored the traditional values disruptive, involve meetings, ambiguity, brevity,
Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal fragmentation and variety. A clinician is used to set and is something the new manager might find clinical care. This connects with the existence of A manager needs to be aware of the different having clear and well defined tasks. However difficult to grapple with. Bolman and Deal assume that a clinician. Once a clinician becomes a manager dimensions in an organizational context. According management work is fragmented and role clarity the allocation of scarce resources and subsequent the connection with saving lives and clinical care to Bolman and Deal a manager should be able to is a source of conflict for the manager. Managers differences might make conflict a central role within somewhat diminishes. Management is concerned relate issues within the structural, political, cultural generally work on one issue and then move on the organisation3. The new manager might find
with quality, performance, resources, employee and human resource frames3. By putting things
to another problem quite rapidly and the previous oneself in constant frustration about how to handle management and resolving organisational issues. in context according to the frames the somewhat issue may not be resolved fully. A new manager the situation without causing conflict or damaging There is no direct link with what the manager used hazy pictures becomes clear and a manager may not be equipped to deal with such ambiguous relationships with other colleagues. This could result to do as a clinician. Social structure consisting of can respond accordingly. Contemporary health work. According to Prideaux new managers are in low morale and lack of motivation and could lead to recurring patterns of behaviour including values, services managers need skills in leadership, risk generally surprised about characteristics of the depression and dissatisfaction. Resource allocation rituals, practices, beliefs and meanings are management and flexibility15. A lack of this skill
new job8. Compounding the problem is a lack of can be simplified by having appropriate policies in
often difficult to modify11. A feeling of isolation might result in confusion and frustration with oneself
formal management training to prepare managers place which will guide resource allocation. and nostalgia may affect the performance of the in being unable to relate to issues. Health manager for their new roles9. Adding to the confusion was
manager at the new job. In this context culture is are being increasingly given more corporate the general lack of senior management support and Human Resource Frame
important and in making the break from past culture responsibility and this places more demands on mentoring. In most instances new managers were Furthermore, a manager has to manage the and assimilating a new culture a new manager will managers to perform. Transition therefore can be left to be on their own and isolated. This could have human resources of the organization well which need support of senior management. challenging due to differences in values, however far reaching performance related consequences for is another organisational frame. Human resources despite the initial stormy period, things should the manager. To illustrate this Van Sell and others in are the key to achieve organizational aims and Finally, a major challenge for a new manager is normalise once the manager has learnt how to work Godwin infer that work related role conflict can result goals. A clinician's training does not include how to the handling of relationships with past colleagues. things out in an organisational context.
in lower productivity, tension, dissatisfaction and maximise the human resources of an organization. Past relationships are treasured; however it can psychological withdrawal10. Appropriate orientation Bolman and Deal's human resource frame assumes
become a problem point for the new manager. References
into the new job and mentoring would help alleviate certain elements which could be important to a To demonstrate this Forbes and Hallier found 1. Lawson J, Rotem A. From clinician to man- some of these problems. Formal training in health new manager3. The first assumption is that the
out those reluctant managers sensing the fear of ager: An introduction to hospital and health management will aid the manager greatly.
existence of organizations is to fulfil human needs rejection by colleagues would place greater value service management. Sydney:McGraw Hill; and not the other way around. However this does on loyalty to the clinical group rather that embrace 2004.
not necessarily mean that it has to come about at a managerial identity12. Past colleagues generally 2. Abbasi K, Edwards N, Marshall M, McLellan A.
Thirdly, a new health manager might have the expense of organisational needs. Secondly, would expect favours or leniency from the new Doctors and managers: a problem without a difficulty with handling the power that comes with employees and organizations both depend on each manager. In addition Braithwaite suggests that solution. BMJ. 2003 March 22; 326(7390): the position. Bolman and Deal includes power other. Employees require jobs, remuneration and clinicians would want the manager to represent 609–610.
within the political frame3. Clinicians are normally opportunities whilst organizations need ideas, vigour
them and their interests, lobby for more resources 3. Bolman LG, Deal TE. Reframing organizations: accustomed to expert power; however the power and ability. There has to be a mutual understanding and be flexible on them rather than demanding13. Artistry, choice and leadership. San Francisco:
derived from a position is something different. between both in order to fulfil the requirements of On the other hand Feldman confers that conflict Jossey Bass; 2008.
Prideaux notes that the authority and responsibility each. Imbalances will result in conflict. Furthermore, arises from multiple and conflicting allegiances 4. Harris MG et al. Managing health services: of a clinician for patient care was straightforward if there is a mismatch between the individual and to subordinates and superiors and personal and Concepts and practice. Sydney: Mosby while on the other hand in organisational terms the organization the result would be that one or both professional values14. However, Thorne notes that Elsevier; 2006.
many people had their say in matters and might might suffer leading to exploitation by one or both. although clinicians respond more favourably to 5. Alexander JA, Rundall TG, Hoff TJ, Morlock dispute about what was done8. Confusion arises For example the employees and the organisation
other clinicians, exerting managerial authority over LL. Power and politics. In Health Care Man- because decisions involving expert power are barely should both share common values. Differences in clinicians' remains unacceptable and unworkable6. agement:
questioned, in comparison to decisions involving values would result in one taking unfair advantage If this does not reciprocate relationships might turn Organization Design and Behaviour. New York: position power. In addition the new manager has of the other. Moreover, a good match will benefit unpleasant. However in an organisation context Thomson Delmar Learning; 2006.
power over his colleagues who were previously his both as the needs and requirements of both parties the manager has to be aware of the organisational 6. Thorne ML. Myth – management in the NHS. peers. How the manager exercises this power over would be met. Human resources require support, obligations and not try to focus too much attention Journal of Management in Medicine. 1997; 11 them would have implications for relationships with mentoring, guidance and self-fulfilment. Once these on his/her former department. Achieving a (3): 168-180.
colleagues. Furthermore power is also an important needs are addressed the human resources will work balance between the organisational goals and the 7. Braithwaite J. Identifying the elements in the tool for the distribution of scarce resources within towards achievement of organisational goals. expectation of former colleagues would be difficult Australian health service management revo- the organisation. Harris asserts that in order to issue. A new manager will in certain situation need lution. Australian Journal of Public Administra- be successful clinician managers have to acquire Symbolic Frame
to make the hard decisions. Any decision should be tion. 1993 December; 52 (4): 417–430.
a new political context in the management of Moreover, cultural values within the organisation in line with organisational goals and not to gratify 8. Prideaux, G. Making the transition from Health resource4. A manager has to handle the resources are a dimension of the symbolic frame of Bolman
any individual or group. Disappointments may be Professional to Manager. Australian Health of the organisation in a way that is most effective and Deal3. A clinician holds dear what he/she
met with resistance, but the manager should be Review. 1993: 16 (1); 43-50.
and beneficial to the organisation. A clinician's does in every day work. One of the major things of able to draw the line when required. 9. Briggs D, Cruickshank M, Fraser J, Minichiello professional knowledge does not include this skill cultural significance is the act of saving lives and V, Taytiwat P. Lessons from understanding the Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal role of community hospital director in Thailand: otherwise rare in a healthy person. Clinical manifes- illary sinuses, hazy bilateral frontal sinuses, and di- kin's Lymphoma (NHL)3. The latter ones are com-
clinician versus manager. Int J Health Plann tation of any of these conditions marks the state of agnosis of pansinusitis was made. He was referred monly associated with HIV infection. Distribution Mgmt. 2011 April/June: 26 (2); e48-e67.
the infected person as a case of full blown AIDS. This for surgical opinion, & subsequently was referred to of sarcoma is Maxillary Sinus (63%), Nasal Cavity 10. Goodwin AM. The clinician-manager model includes many types of leukaemia and lymphomas. ENT clinic at the CWM Hospital. Since his initial visit, (35%), Ethmoids (19%), & Frontal and Sphenoid Si- in the National Health Service: Conflicting social The first reported case of plasmablastic lymphoma 1 & ½ months had passed and his facial mass had nuses (1-2%). defence systems? Psychoanalytic Psychothera- (PBL) in Fiji in an HIV seropositive person is reported doubled. During ENT investigations, bilateral nasal py. 1996: 10 (2); 125-133.
biopsy revealed plasmablastic large cell lymphoma, Clinical features:
11. Braithwaite J. An Empirical Assessment of So- and he was referred back to Lautoka Hospital with • Nasal obstruction, nasal drainage cial Structural and Cultural Change in Clinical Key words: Human Immunodeficiency Virus,
recommendation for chemotherapy. • Sinusitis unresponsive to conventional therapy Directorates. Health Care Analysis. 2006 AIDS, Plasmablastic lymphoma, Fiji.
• Otitis media with effusion December: 14 (4); 185-193.
• Mass effect on face and orbits 12. Forbes T, Hallie, J. The role of social identity He completed 4 cycles of chemotherapy, which • Cranial nerve palsies in doctors' experiences of clinical Managing. A 43 year old male presented with left facial cheek comprised of 75% CHOP, with cyclophosphamide, • Complaints often non-specific and results in Employee Relations. 2005: 27 (1); 47-70.
swelling for one month, which started spontaneously, doxorubicin, vincristine, prednisone, after consul- delay of diagnosis 13. Braithwaite J. An empirically-based model for and grew slowly. This swelling started to block the tation with an overseas oncologist. His tumor has clinician-managers' behavioural routines. Journal nasal passage, with on-and-off nasal discharge. He shrunk significantly, and symmetry of face has been Non-Hodgkin's Lymphoma occurs more frequently of Health Organization and Management. 2004: had a history of occasional headaches every other restored. He received one unit of blood before his in HIV+ patients, about 25-60 times than normal 18 (4); 240-261.
day, at times quite severe. Occasionally he also had third cycle, after a significant drop in his haemoglo- population4. Sinonasal site is rare, more common
14. Feldman S. The middle management muddle. complained of dizziness, nausea and vomiting. bin, as a side effect of chemotherapy. He has con- extranodal sites include CNS, digestive tract & Administration in Mental Health. 1980: 8 (1); tinued to take medications and has not encountered bone marrow. It is often accompanied by symp- Past history
any side effects. He is being followed-up at the hub toms of fever, weight loss and malaise. 15. Meyer LD, Hodgkinson AR, Knight R, Ho He has been a known HIV case for the past 3 years, centre and is doing well. He has had no significant Diagnosis of NHL is made on the following basis: MT, Corpo SK, Bhalla S. Graduate and has been on ARVs for 5 months, consisting of illnesses since then, apart from the occasional viral • Clinical exam: Endoscopic evaluation is most capabilities for health service managers: a 3-drug regime with Zidovudine (AZT) 300mg BD, illness. He has been working as a sailor for the last reliable. It may appear as friable, greyish necrotic reconfiguring health management education Lamivudine (3TC) 150 mg BD, and Nevirapine (NVP) 2 years and comes regularly to the clinic to collect lesion (NHL) or red, purple, or black macule or @UNSW. Australian Health Review. 200mg BD. He is also on Co-trimoxazole 960 mg OD his medication, which includes Cotrimoxazole and papule of nasal mucosa (feature of Kaposi's 2007 June: 31 (3); 379-379.
prophylaxis and ferrous sulphate 200 mg TID. As per original ARV regime of Lamivudine, Zidovudine, Sarcoma). WHO classification, he has been determined to be at and Nevriapine (LZN).
• Sinus CT: Best to evaluate for bony erosion Case report
stage 2. He suffers from recurrent sinusitis which is tumor. Critical areas include bony orbits, Plasmablastic lymphoma in AIDS: Case report confirmed by X-ray.
ethmoidrof, and post. maxillary sinus to evaluate and review of literature
Lymphoma is a cancer of the lymphocytes1.These orbital, intracranial, or pterygopalantine fossa
Iane Panjueli, Rahena Mehnaj, Kamal Kishore are of 2 types: Hodgkins and Non-Hodgkins, which invasion. He is married with no children, his wife is HIV posi- are majority of cases. Diseases pathogenesis in- • High resolution or thin cuts recommended. 1. Bailey Clinic, Lautoka tive. He is an occasional smoker. volves abnormal growth of lymphocytes in both B- Contrast CT is usually not helpful.
2. Medical Officer, Lautoka Hub Centre On examination, he was found to be a healthy look- cells and T-cells, although B-cells more common. It • Magnetic Resonance Imaging: Excellent deline- 3. College of Medicine, Nursing & Health ing male with mild disfigurement of his left face and occurs in the absence of any disease, however, in ation of tumor from surrounding inflamed tissue Sciences, Fiji National University no obvious distress. His vital signs were normal. He HIV positive persons, it occurs with high frequency. or secretions and to evaluate intracranial spread.
had obvious asymmetry of facial cheeks, on the left HIV-related Lymphoma is uusually aggressive2.It • Biopsy: Usually done on primary lesion and any
#Address for correspondence: side he had a smooth, shiny protruding mass over is estimated that about 10% of HIV infected persons nodal metastasis. Transnasal intraoperative the left cheek, the size of a golf ball, with erythema. eventually develop lymphoma. Most common lym- biopsy is usually preferred. Evaluate tissue It was non-tender, fixed and firm, pulling onto sur- phomas seen in patients with HIV are: diffuse large using histopathology and immunohistochemisty rounding structures, especially the nose, causing b-cell, Burkitt's / Burkitt-like,p rimary central nerv- Human Immunodeficiency Virus (HIV) infection flaring. His left eye appeared smaller because of this ous system,and Hodgkin lymphoma. • Differential diagnosis: severely affects the immune status of the infected mass. Other systems were essentially normal. A pro- Another variety is sinonasal Lymphoma3. It is • Infectious conditions such as fungal diseases
person. This is a slow process, which, apart from visional diagnosis of tumor, with differential diagnosis associated with Karposi's Sarcoma associated (mucormycosis, aspergillosis, Alternaria, Bipola- the acute HIV illness in some, does not affect the of abscess/cellulitis, infected sinus, or possible side herpesvirus, and EBV. Malignant tumours of the ris, etc) infected person's health in the early stages of the effect of ARVs was made. sinonasal tract in general population is <1%, and it • TB may mimic malignancy. disease. As the disease progresses to a more ad- When investigated, his full blood counts were nor- accounts for 3% of malignancies of the upper res- Biopsy with search for atypical organisms is vanced stage, many of the common infections begin mal; his CD4 counts were found to be 106/mm3. His especially important in this population. to appear at a higher frequency, and for prolonged urea electrolytes creatinine levels & liver functions Most common in varieties in HIV and non-HIV pa- • Inflammatory nasal polyps and pyogenic durations. As the immune deficiency advances fur- tests were normal. In lipid profiles, he was found to tients are Squamous cell carcinoma (45-80%), Sali- granuloma (benign nasal tumor) should also be ther, it predisposes the person to a variety of life have mildly elevated triglycerides. vary gland carcinoma (5-15%), & Sarcomas (5%), considered.
threatening cancers and opportunistic infections, A PNS X-ray showed opacification of bilateral max- which include Kaposi's Sarcoma and Non-Hodg- For treatment of Non-Hodgkin's Lymphoma, ag- Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal gressive chemotherapy is the treatment of choice. normal life. Recently, WHO initiated a campaign to 8. Secretariat of Pacific Community public health and lower limb pain which escalated with mobiliza- Regimens include CHOP (cyclophosphamide, dox- promote treatment as prevention as a strategy to division (spc.int/sdp) accessed June 2013. tion. Generalized swelling involved facial puffiness, orubicin, vincristine, prednisone) or EPOCH (etopo- stop the incidence of new infections10.
9. MaciuMaloITaukei top HIV list. Fiji times abdominal distention and lower limb swelling. His side, vincristine, cyclophosphamide, doxorubicin, Plasmablastic lymphoma was described as a new (http://www.fijitimes.com/story.aspx?id=245038) itchiness was generalized but marked on the limbs. prednisone). Both regimens are often given with entity associated with HIV infections in 1997.11Since ac-cessed on 09 October 2013. The patient described as being short of breath af- rituximab. Non-responders may require local radio- then, the frequency of this peculiar entity has 10. Antiretroviral treatment as prevention (TASP) ter about a 30 meter walk or climbing stairs. therapy, or rarely surgical resection. Follow up of increasingly been reported among HIV positive of HIV and TB. WHO June 2012 Past history revealed that he had been investi- NHL requires close monitoring by oncology. NHL population in various parts of the world12.
11. Schmidt-Westhausen, P.A. Reichart et al, Plas- gated for chronic diarrhoea in November, 2009, usually has poor prognosis5.
Opportunistic infections and AIDS associated mablastic Lymphomas of the Oral Cavity: A New was treated for amoebiasis and subsequently im- cancers pose a serious challenge to any resource- Entity Associated With the Human Immunodefi- proved. He was diagnosed to have dyslipidemia in limited setting, for the purposes of accurate diagnosis ciency Virus Infection. Blood 1997 (89): 1413-1420 April, 2010, managed with Atorvastatin 40mg nocte and management. Laboratory facilities for diagnosis 12. Beral V, Peterman T, Berkelman R, Jaffe H: and afterward lost to follow up. The patient was not The first article on HIV infection was published in of these conditions require advanced techniques and AIDS-associated non-Hodgkin lymphoma. Lancet on any regular medications at time of admission expertise. Special stains, culture facilities, expensive May 1981, reporting an incidence of Pneumocystic and had no known allergies and his family history technologies such as immunofluorescence and pneumonia in 5 young but otherwise healthy revealed his father suffered from hypertension, dia- molecular diagnostic tools are resource intense, Case report
males6. This report marked the beginning of the
betes mellitus type 2 and stroke. He worked as a require specialied training and stringent quality Hypereosinophilic Syndrome: A rare
HIV pandemic. 2011 was marked globally as the farmer, did not take alcohol and cigarettes but oc- assurance measures for their validity and accuracy, differential diagnosis for profound
30th year of the HIV pandemic. Since the beginning casionally took kava.
yet they are needed for a focused and small target of this epidemic, there have been an estimated 30 On examination, he was an obese man with nor- group. Therefore, investment in these areas often Dipesh Raniga, Medical Registrar, Lautoka Hospi- million infections globally, with maximum impact in mal vital signs. He was pale and his eyes looked becomes hard to justify. Fiji and much of the Pacific tal, Fiji Islands the sub-Saharan region of Africa7. Different parts of
puffy. There were no palpable lymph nodes. His lacks these resources. As more and more HIV the world have been affected at different rates. In the heart sounds were normal. His respiratory examina- William May, Consultant Physician, Assistant Pro- Pacific, the first reported case in Papua New Guinea positive persons start their antiretroviral therapy, tion revealed bibasal coarse crepitations. Abdomi- non-compliance & defaults, drug resistance etc. fessor Internal Medicine, College of Medicine Nurs- in 1987 marked the beginning of the HIV pandemic nal examination was normal. Extremities revealed ing and Health Sciences, Fiji National University.
in the region. In Oceania, however, the first case would put them at risk of developing-AIDS related thickened skin in right forearm (Figure 1) and exfo- complications, putting diagnostic services under was reported as early as in 1982 in Australia. liative erythematous rashes on his legs (Figure 2) Litia Tudravu, Consultant Pathologist, Lautoka Hos- The Pacific has largely remained a low incidence strain. extending up to the thighs and also on his back.
pital, Fiji Islands region, with the exception of Papua New Guinea, References:
which bears the brunt of the epidemic (UNAIDS). In the South Pacific, there are 4 focal points of 1. Swerdlow, S., Campo, E., Harris, N., Jaffe, E., Pileri, S., Stein, H., Thile, J., and Vardiman, continuous reported cases of HIV8. Two of them J., Eds. WHO Classification of Tumours of the
are in French territories (New Caledonia & French Haematopoietic and Lymphoid Tissues. IARC A broad range of disorders are present with eo- Polynesia), one is an American protectorate (Guam). 2008.
sinophilia and these include infectious, allergic, The fourth one is Fiji, with 482 reported cases as of 2. Castillo, J., Reagan, J,. Plasmablastic Lym rheumatic, neoplastic, endocrine and idiopathic dis- December 20129. While three of the most affected phoma: A Systematic Review The Scientific World
orders which range from benign to life-threatening focal points are under French and American care, JOURNAL 2011 (11), 687–696 illnesses. All these conditions create a heteroge- ensuring optimal treatment and care is available 3. Abrams DI. Acquired immunodeficiency syn- neous list of clinical presentation that patients may for their HIV infected populations, Fiji is largely on drome and related malignancies: a topical over display, thus creating a diagnostic challenge for cli- its own in this regard. After the Global Funds round view.SeminOncol. 1991 Oct;18 (5 Suppl 7):41-5. nicians. We present a patient with a broad range 2 grant, which concluded in 2007, no new donor 4. Thomas JO. Acquired immunodeficiency syn- of clinical features and hematological counts that fit initiated major grant has become available. Despite drome associated cancers in Sub-Saharan into the diagnosis of Hypereosinophilic Syndrome that, MOH Fiji has ensured treatment and care are Africa. SeminOncol. 2001 Apr;28(2):198-206.
(HES). He was investigated reasonably to rule the optimally provided through its core funding. Fiji 5. Bertrand FE, McCubrey JA. Acquired immuno- various possible differentials and subsequently leads the rest of the region in being proactive on deficiency syndrome associated lymphoma. Front started on Prednisone therapy.
various fronts to ensure key affected populations in Biosci. 2005 Sep 1;10:2972-7 the country are cared for. 6. MMWR Pneumocystic pneumonia-Los Angeles Key Words: Hypereosinophilic Syndrome, FI-
In the past 30 years, a great deal of knowledge as June 5, 1981 / 30(21);1-3 well as progress on management of HIV infection 7. UNAIDS report on the global AIDS epidemic 2013 has been achieved (UNAIDS). While there is still (http://www.unaids.org/en/resources/campaigns/ no cure or vaccine available, with current treatment global-report2013/globalreport/), accessed on 09 A 54-year-old male was referred from one of the options, HIV can be managed as a chronic infection, Figure 1: Thickened right forearm skin
rural health centers with 6 months history of gener- which allows the infected person to live a near- alized swelling, pruritis and worsening shortness of breath on exertion and a 2-year history of back pain Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal The patient's full blood count showed normocytic impaired relaxation pattern indicative of Stage II Di- Chromosomal studies for the bone marrow aspi- 1. Chusid et al in 1975 used a diagnostic criteria for
anaemia with a hemoglobin of 7.9g/dL and a white astolic dysfunction.
rate showed no BCR/ABL 1 gene rearrangement HES1, 5, 6:
cell count of 409800/µL with more than 85% eosin- A skin biopsy (figure 4) was taken from the thick- and further studies revealed no F1P1L1/CHIC2/ 2. Persistent eosinophilia of 1.5 x109/L (1500/
ophils (figure 3). ESR was elevated at 100mm/hr. ened skin of the right forearm for histological studies PDGFRA gene rearrangement.
mm3) for longer than 6 months; His kidney functions were normal and liver function which showed perivascular eosinophilc infiltration in The diagnosis of hypereosinophilia was made and 3. Lack of evidence for parasitic, allergic, or other
tests revealed a mildly raised ALP of 211U/L. The dermis, suggestive of eosinophilicvasculitis. the differentials included hematological malignan- known causes of eosinophilia; and Vitamin B12 level was low at 42ng/L. His chest x-ray cies or idiopathic cause. The available literature on 4. Signs and symptoms of organ involvement
showed evidence of cardiomegaly with normal lung hypereosinophilia showed that allergies, infections fields and ECG had normal findings. Antinuclear an- and autoimmune processes were frequently as- In a more recent literature, it has been indicated tibodies (ANA) were negative.
sociated with mild to moderate hypereosinophilia that the 6 month time period requirement is less
and the serum was negative for ANA and so these frequently used due to advanced and accessible
processes were ruled out. A malignant process was testing methods2,5,6,9. Hypereosinophilia is cat-
also ruled out since the vitamin B12 level was not egorized using the absolute eosinophil count into
elevated, chromosomal studies were negative, the mild (0.5-1.5 x 109/L), moderate (1.5-5 x 109/L) and
bone marrow showed dysplastic changes in less severe (> 5 x109/L)12.
than 5% of eosinophils and clinically he did not have
A retrospective study had demonstrated that the signs or symptoms frequently associated with a ma- most common clinical manifestations associated Figure 3: Peripheral Blood Smear: Shows
lignant pathology such as weight loss and hepato- with hypereosinophilia were weakness and fatigue (26%), cough (24%), dyspnoea (16%), myalgias or The patient was initially started on Lasix 20mg angioedema (14%), rash or fever (12%), and rhinitis once daily with low dose aspirin for his diastolic dys- function. Once the possible differentials were ruled The pathophysiology of HES is sequestration of out, the patient was assessed to have idiopathic hy- eosinophils into organ tissues. Any organ system pereosinophilic syndrome (HES) and evidence sug- maybe associated with HES1,2,8,11, 12. A retro-
gested the use of steroids to bring down the eosino- spective study showed that the most common being phil count to prevent further end-organ damage.
dermatological manifestations were found in 69% of He was initiated with Prednisone of 60mg daily patients, 44% of patients had pulmonary manifesta- and reviewed a week later. His WCC dropped to tions, 38% had gastrointestinal and 6% had cardiac 238240 cells/µL. After 2 weeks, he was less symp- involvement which increased to 20% in subsequent Figure 4: Skin Biopsy: Perivascular infiltration
tomatic and had a white cell count that dropped to follow-ups11. Eosinophil derived neurotoxin, peroxi-
34370 cells/µL, so his Prednisone dose was tapered dase, eosinophilic cationic protein and major basic to 50mg once daily. proteins are enzymes released by eosinophils that Bone marrow aspirate (figure 5) and trephine bi- On his most recent review, the white cell count cause endothelial damage and promote fibrosis, opsy was carried out and it showed hypercellular was 10010 cells/µL with an eosinophil count of 4905 thrombosis and infarction.10,12.
fragments due to markedly increased eosinophils cells/µL. He still complained of generalized itchi- The classification of Hypereosinophilic Disorders and eosinophil precursors with normal maturation ness but had no shortness of breath on exertion nor varies due to ongoing research and updates from pattern. No increase in blasts and no dysplasia generalized swelling. His dose of Prednisone was various studies. A convenient form of classification were reported in other cell lines.
reduced to 35mg once daily. In his subsequent re- is mentioned by Gotlib et al1. and again by Tefferi
Figure 2: Erythematous exfoliative rashes in
views, the Prednisone dose is to be further tapered et al12:
down and an immunosuppressant added. 1. Reactive
2. Clonal
The patient's full blood count showed normocytic anaemia with a hemoglobin of 7.9g/dL and a white The term hypereosinophilic syndrome (HES) is syn- Reactive causes of Hypereosinophilia need to be cell count of 409800/µL with more than 85% eosin- onymous with idiopathic hypereosinophilia, was ruled out first and these include: ophils (figure 3). ESR was elevated at 100mm/hr. thought up in 1968 by Hardy and Anderson to de- • Parasitic Diseases- Helminthes, tapeworm, His kidney functions were normal and liver function scribe the groups of patients with unexplained high Filiariasis etc tests revealed a mildly raised ALP of 211U/L. The eosinophil counts with end-organ damage1,5,6. • Allergic Diseases- asthma, Atopic Dermatitis etc
Vitamin B12 level was low at 42ng/L. His chest x-ray There has not been much research done on hypere- • Immunologic Diseases- Rheumatoid Arthritis, showed evidence of cardiomegaly with normal lung osinophilic syndrome due the rarity of the condition, Churg-Strauss Syndrome, Wegner's Granulama fields and ECG had normal findings. Anti-nuclear Figure 5. Bone Marrow Aspirate Smear: Eosino-
incidence rate of 0.036 per 100000 population,2. tosis etc
antibodies (ANA) were negative.
phils at various stages of maturation with dys-
with a male to female ration of 9:1 • Neoplasms- Mastocytosis, T-cell lymphomas, A Trans-thoracic Echocardiogram study showed plastic changes
Hodgkin's Lymphoma etc1,3,13.
Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal The reactive causes usually give rise to mild or transformation to T-cell lymphoma or S'ezary Syn- produced reduced eosinophilic counts in selected 9. Roufosse F, Weller PF. Practical approach to moderate peripheral eosinophilia and represent a drome2,16.
cases of Idiopathic HES25,27.
the patient with hypereosinophilia. J Allergy physiologic response by bone marrow to increased Research has demonstrated finding T-cell clonal- Novel approaches to treat HES are still under- ClinImmunol. 2010 July; 126(1): 39–4410. Leiferman KM, Gleich GJ. Hypereosinophilic tissue demand for eosinophils. The eosinophilia ity by detecting TCR gene rearrangements and ab- going trials with newer Tyrosine Kinase Inhibitors syndrome: Case presentation and update. ceases or declines with cessation of the causative normal T-cell immunophenotype (e.g. CD3-CD4+, showcasing more potency, efficacy, fewer adverse J Allergy ClinImmunol. 2004;113 (1): 50-8.
CD3+CD4-CD8- or CD4+ CD7- ). Elevated levels effect profiles or ability to treat resistant cases2, 11. Ogbogu PU, Bochner BS, Butterfield JH,
Once possible reactive causes are ruled out clini- of IgE, thymus and activation-regulated chemokine . Hypereosinophilic syndromes: A multicenter, cally or by laboratory investigations, the attention (TARC), cytokines (esp. IL-5, IL-4 and IL-13) pro- retrospective analysis of clinical characteristics and response to therapy. J Allergy ClinImmunol shifts to look for clonal causes of eosinophilia which duced due to these abnormal T-cells provides sup- 2009 December;124(6):1319–1325.
includes mainly Chronic Eosinophilic Leukemia port for lymphocytic variant2,6,11,16,15,17.
BCR/ABL1 - Breakpoint cluster region/Abelson 12 Tefferi A, Patnaik MM, Pardanani A. Eosino- Anemia and thrombocytopenia are common he- philia: secondary, clonal and idiopathic. Brit J of The laboratory investigation for CEL is centered matological changes in addition to the raised white F1P1L1 - Fip1- like1 Haemat. 2006 June; 133 (5): 468–492 on determining the presence of FIP1L1/PDGFRA cell count with predominantly eosinophils ranging CHIC2 - Cysteine-rich hydrophobic domain 2 13. Sims KL. Peripheral Eosinophilia and Diagnosis of Hypereosinophilic Syndrome. fusion gene. The gene is created by a deletion on from 1500-400000/µL.
LABMEDICINE. 2006 July; 37(7): 440-442.
the 4q12 gene leading to the creation of the fusion Smears from the blood and marrow show varying PDGFRA- Platelet Derived Growth Factor Alpha 14. Tefferi A, Gotlib J, Pardanani A.Hypereosinophilic gene1,2,6,7. The median prevalence of FIP1L1/
degrees of mature, immature cells and cell dyspla- PDGFRB- Platelet Derived Growth Factor Beta Syndrome and Clonal Eosinophilia: Point-of-Care PDGFRA fusion gene in a review of eight published sia. Charcot-Leyden Crystals are a common finding CEL - Chronic Eosinophilic Leukemia Diagnostic Algorithm and Treatment Update. studies of hypereosinophilic patients was 23% (3- in bone marrow smears2. Elevated levels of Vita-
CEL, NOS - Chronic Eosinophilic Leukemia, Not Mayo Clin Proc. 2010 Feb; 85(2):158-164 15. De Lavareille A, Roufosse F, Schmid-Gren min B12 are common in malignancies associated delmeier P, Roumier AS, Schandene L, Cogan Negative FIP1L1-PDGFRA fusion calls for assess- with eosinophilia6,7,11. Serum Tryptase levels are
FGFR1 - Fibroblast growth factor 1 E, Simon HU, Goldman M. High serum thymu ment of other clonal hypereosinophilias associated elevated in the CEL namely FIP1L1-PDGFRA posi- TCR - T Cell Receptor sand activation-regulated chemokine levels in with recurrent molecular defects such as PDGFRA tive, and can be used as a substitute marker if cy- the lymphocytic variant of the hypereosinophilic with other fusion partners on 4q12, PDGFRB on togenetic studies are not easily available2,11.
syndrome. J Allergy ClinImmunol. 2002 Sep;110(3): 476-9.
5q31-33, or FGFR1 on 8p11-132. Malignant clones
Such extensive investigations were not carried out 1. Gotlib J, Cools J, Malone JM III, Schrier SL, 16. Simon HU, Plotz SG, Dummer R, Blaser K: Ab of eosinophils are also associated with systemic in our setting due to limited resources, cost of tests Gilland DG, Coutr'e SE. The FIP1L1-PDG FRa fusion tyrosine kinase in hypereosino- normal clones of T cells producing interleukin-5 mastocytosis, myelodysplastic syndromes (MDS), and treatment modalities not being readily and rea- philicsyndrome and chronic eosinophilic leuke- in idiopathic eosinophilia. N Engl.J Med.1999 acute myeloid leukemia, chronic myeloid leukemia sonably available.
mia:implications for diagnosis, classification, Oct 7, 341(15):1112-1120.
17. Vaklavas C, Tefferi A, Butterfield J, Ketterling (CML) and other myeloproliferative disorders and Most patients with Eosinophilia are initially clas- and management. Blood. 2004 April 15; 103 R, Ver-stovsek S, Kantarjian H, Pardanani A. thus need to be considered1,2,6.
sified as Idiopathic Hypereosinophilia (HES), after 2. Gotlib J. World Health Organization-defined eo- ‘Idiopathic' eosinophilia with an Occult T Chronic Eosinophilic Leukemia, Not Otherwise preliminary clinical analysis and various investiga- cellclone: prevalence and clinical course. Specified (CEL, NOS) is classified under clonal sinophilic disorders:2011 update on diagnosis, tions are inconclusive. Subsequent manifestations risk stratification, and management. Am. J. Leuk Res 2007 May, 31(5):691-694.
causes of eosnophilia and so should be considered of the disease process and/or further tests may re- Hematol. 2011; 86: 678–688.
18. Cortes J, Ault P, Koller C, Thomas D, et al. Efficacy of imatinibmesylate in the treatment of if there is absence of the PDGFRA/B or FGFR1 as veal a clonal or reactive pathology2,3,5.
3. Kalac M, Quintas-Cardama A, Vrhovac R, idiopathic hypereosinophilic syndrome. Blood. there may be evidence of clonality but this is not The consensus among experts is that Imatinib Katarjian H, Verstovsek S. A Critical Appr- 2003 Jun 15; 101(12):4714-4716 classifiable with the cytogenetic and/or morphologic provides definitive treatment for PDGFRA/B rear- aisal of Conventional and Investigational Drug Therapy in Patients With Hypereosinophilic 19. Klion AD, Robyn J, Akin C, et al. Molecular studies2. CEL, NOS may be distinguished from HES rangements2,7,30. Numerous studies have shown
remission and reversal of myelofibrosis in Syndrome and Clonal Eosinophilia. by the presence of a nonspecific clonal cytogenetic its efficacy to produce hematologic and cytogenetic Cancer. 2007 Sept 1; 110 (5): 922-964.
response to imatinibmesylate treatment in abnormality or increased blast cells (>2% in the pe- remissions18-22,30. Doses from 100mg- 400mg
4. Rothenberg ME, Klion AD, Roufosse FE, et al. patients with the myeloproliferative variant of hypereosinophilic syndrome. Blood. 2004 ripheral blood or >5% in the bone marrow, but <20% daily produced remission and the patient may be Treatment of patients with the hypereo- Jan 15; 103(2):473–478.
blasts in both compartments)1,2.
maintained on as low as 100mg weekly23.
sinophilic syndrome with mepolizumab. New Engl. J Med. 2008;3589(12): 1215–1228.
20. Jovanovic JV, Score J, Waghorn K, et al. Low- The lymphocytic variant hypereosinophilia in- For patients with HES, CEL-NOS and lymphocytic 5. Roufosse F, Cogan E, Goldman M. Recent dose imatinibmesylate leads to rapid induction volves abnormal T-cells which excessively produce variant hyper-eosinophilia, recommendations are advances in pathogenesis and management of majorvmolecular responses and achievement cytokines (e.g. IL-5) and causes excessive produc- to treat with steroids, such as Prednisone at 1mg/ of hypereosinophilic syndromes. Allergy. 2004; of complete molecular remission in FIP1L1 PDG FRA-positive chronic eosinophilic tion of IgE, thus promoting the production of eo- kg which rapidly reduce eosinophil counts and can 59: 673–689.
leukemia. Blood 2007 Jun 1; 109(11): 4635–4640.
sinophils in bone marrow2,6. The condition has a be gradually tapered24. The use of steroids for long
6. Roufosse F. Orphanet Journal of Rare Diseases. 2007 Sept 11; 2 (37): 21. Baccarani M, Cilloni D, Rondoni M, et al. The combination of both reactive and clonal mechanism periods comes with numerous side effects and so efficacy of imatinibmesylate in patients with FI 7. Antoniu SA. Novel therapies for hypereosino- and thus creates a dilemma in its classification. The necessitates tapering to the lowest possible dose philic syndromes.The Netherlands Journal of P1L1-PDGFRal-pha-positive hypereosino- patients usually present with dermatological mani- and adding other drugs that can be used alone or in Medicine. 2010 July/August; 68 (7/8): 304-310 philic syndrome: Results of a multicenter prospective study. Haematologica. festations 1,2,9. There is no consensus for the di-
conjunction to the steroid therapy.
8. Karnak D, Kayacan O, Beder S, Delibalta M. 2007 Sep; 92(9):1173–1179.
agnosis of the lymphocytic variant2. This condition
These drugs include Hydroxyurea (most common- Hypereosinophilic syndrome with pulmonary and cardiac involvement in a patient with 22. Pardanani A, Ketterling RP, Li CY, et al. FIP1 has a prevalence of about 17% in hypereosinophilic ly used), Interferon-α (IFN-α), Vincristine, Cyclo- asthma. Canadian Med. Assoc. J. 2003 Jan 21; L1-PDG FRA in eosinophilic disorders: Preva patients11 and has a tendency to have malignant phosphamide. Imatinib used at high doses has also
168 (2): 172-175.
lence in routine clinical practice, long-term expe Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal rience with imatinib-therapy, and a critical review ventions which leads to improved programme per- be excluded from the actual training. This was be- by them to change policy and practice.
of the literature. Leuk Res 2006 Aug; 30 (8): formance and/or health service delivery1-3. This
cause the Union's experience has shown that indi- science has long been used in developed countries viduals on these positions are already overwhelmed Future of OR training
23. Helbig G, Stella-Holowiecka B, Majewski M, et al. A single weekly dose of imatinib is sufficient such as Europe to improve health systems opera- with their daily administrative duties of program im- During the first round of Fiji OR capacity building to induce and maintain remission of chronic eo tions and thus performance. Over the past decade, plementation and may not have the necessary time training, the majority of the participants were hand- sinophilicleukaemia in FIP1L1- PDGFRA-ex OR is being conducted in health systems in re- to undertake the training and achieve the pre-deter- picked. As such, due consideration was not given to pressing patients. Br J Haematol 2008 Apr; source limited settings such as Sub Saharan Africa mined milestones attached to each module of the 3 whether they were keen to participate and develop 141(2): 200–204.
and now in Asia and more recently in the Oceania module OR training. their skills in research. In addition, the majority of 24. Gotlib J, Cools J. Five years since the discovery of the FIPL1-PDGFRA: What we region. As such, teams of proposal writers seeking Post OR symposium, the Union's three-module those who commenced the training were not only have learned about the fusion and other funds from international health aid donors have fac- model of OR commenced with a class of 12 par- unaware of the OR but also its associated mile- molecularly defined eosinophilias. Leukemia tored funding for operational research in health pro- ticipants. Each module was three months apart and stones. These two factors required a great deal of 2008; 22: 1999–2010.
grams so that the concept of OR can be introduced consisted of lectures, sessions with mentors as well effort in following up with each researcher on their 25. Butterfield JH. Success of short-term, higher- in this part of the region and capacity can be devel- as plenary sessions. Each module had milestones individual project implementation and completion. dose imatinibmesylate to induce clinical response in FIP1L1-PDGFRalpha negative oped among health staff to conduct OR. which participants need to achieve after completing Now that these individuals have returned to their hypereosinophilic syndrome.Leuk Res 2009 OR Training
the module. Module 1 required participants to de- programs, it is imperative that they engage in OR. Aug;33 (8):1127–1129.
The OR capacity building training was one of the velop research question and protocol and complete In future OR capacity building training, it is vital that 26. Hart TK, Cook RM, Zia-Amirhosseini P, et al. key deliverables of the Global Fund (Global Fund an ethics form, along with any data collection instru- individuals are selected appropriately both by merit Preclinical efficacy and safety of mepolizumab for AIDS, Tuberculosis and Malaria –GFATM) Grant ments, with the assistance of experienced OR men- and their career aspirations. The CMNHS com- (SB-240563), a hu-manized monoclonal antibody to IL-5, incynomolgus monkeys. J for which the principal recipient (PR) was Ministry tors. The milestone for module 1 was submission of menced the second round of OR training in May, Allergy ClinImmunol 2001 Aug;108 (2):250–257 of Health (MOH), Fiji. The round 8 & 9 grant was these documents to ethics committees. Module two 2013 to be completed in February 2014 to further 27. Helbig G, Hus M, Halasz, et al. Imatinib- specifically for Tuberculosis (TB) and Health Sys- introduced participants to Epidata5 software (open build capacity amongst additional twelve staff of the
mesylate may induce long-term clinical response tems Strengthening (HSS). The College of Medi- access software) and taught them how to develop SR of the GFATM grant.
in FIP1L1-PDGFR a negative hypereosinophilic cine, Nursing and Health Sciences (CMNHS) of the a data entry template based on the variables in their syndrome. MedOnc. 2011 Jan 22. (Epub ahead Fiji National University (FNU) was one of the sub- protocol and steps to data analysis. Between mod- 1. http://www.ncbi.nlm.nih.gov/pmc/articles/ 28. Verstovsek S, Tefferi A, Kantarjian H, et al. recipients (SR) of the grant, tasked to deliver the ule 2 and module 3, participants were required to Alemtuzumab therapy for hypereosinophilic syn OR capacity building training to staff of other SR collect data (mostly from registers at health facili- drome and chronic eosinophilic leukemia.Clin including CMNHS staff. Due to the absence of local ties) and analyse data. The submission of the ana- 2. Kumar, A.M.V, Satyanarayana, S et al. Opera- Cancer Res 2009 Jan 1; 15(1): 368–373.
capacity for this genre of research, the World Health lysed data was the milestone for module 2. During tional Research capacity building in Asia: in- 29. Sefcick A, Sowter D, DasGupta E, et al. the final module, participants wrote up a scientific novations, successes and challenges of a Alemtuzumab therapy for refractoryidiopathic Organisation (WHO) was consulted. The then WHO training course, Public Health Action, vol. 3, hypereosinophilic syndrome. Br J Haematol TB Advisor assisted CMHNS to established with paper based on the initial protocol they developed, 2004 Feb;124(4): 558–559.
the International Union Against Tuberculosis and incorporating the study findings. Once the paper June,pp. 186-188.
30. Cools J, DeAngelo DJ, Gotlib J, et al. A tyros Lung Disease (The Union) which has the world was written, participants were required to make on- 3. Bissell, A.,Harries, A.D et al. Operational re ine kinase created by fusion of the PDGFRA and authority on OR. Soon after establishing contacts line submission as their final milestone; of course search training: the course and beyond, Public FIP1L1 genes as a therapeutic target of imatinib Health Action, vol.2, September, pp.92-97.
in idiopathic hypere-osinophilic syndrome. N with the Unions, numerous online and e-discussion they were taught how to do this. For the Fiji course, 4. Zachariah R, Harries AD, et.al IN. Operational Engl J Med. 2003 Mar 27; 348: 1201–1214.
took place between the College and OR experts of 8 participants made it through the three modules, 31. Fauci AS, Harley JB, Roberts WC, et al. the Union on how the OR training model used by with 4 drop-outs. The reasons for dropping out in- research in low-income countries : what, why and The idiopathic hypereosinophilic syndrome.
the Union could be brought to the Oceania region. cluded a change in profession of the participants, how? Lancet. 2009;9:711-7.
Clinical, Pathophysiologic, and Therapeutic Since there was general lack of knowledge of what, unapproved OR protocol and failure to meet the 5. http://www.epidata.dk/ considerations. Ann Intern Med 1982 Jul;97(1):78-92 why and how of OR4, it was decided that the OR
milestone by deadlines. From eight (8) participants, training will proceed with a 2-day OR symposium. nine (9) study papers were written (since one partic- The symposium was targeted at novice OR partici- ipant wrote 2 papers). In terms of publication, seven Operational Research capacity building in Fiji
pants, public health professionals, academics, staff (7) papers have been published to date from the of MOH and most importantly, senior MOH staff pioneer Fiji OR course, recording a success rate Sharan Ram, Prithika Prasad, & Kamal Kishore including program managers so that they became of 58 per cent. Two papers are under review. Since College of Medicine, Nursing & Health Sciences, aware of what the OR course will entail, both in the main objective of the OR is to help improve Fiji National University terms of the amount of time and financial resources health systems, the findings of the OR studies was needed so that they could be supported when they presented during a dissemination seminar in which Address for correspondence: return to the programs after the completion of the program managers, staff of the health ministry and training. Apart from learning the what, why and how academics were invited. Apart from delivering the Operational Research (OR) is defined as the of the OR, one of the key issues highlighted during presentations, individual researchers also prepared the symposium was that senior program managers action plans for the MOH so that this could be used search for knowledge on strategies, tools or inter- Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal Book review
By Francis X. Hezel, SJ
Late Dr Umanand Prasad, the philanthropist
sire and conviction to give back to Fiji. Don't Ever Whisper - Darlene Keju: Pacific Health Pioneer, Champion for Nuclear Survivors, by Giff John- It was with shock and disbelief that we at UPSM Dr Prasad was born into a very poor family in La- heard of the sudden passing away, of Dr Umanand basa and struggled with poverty in his childhood Publisher: CreateSpace Independent Publishing Prasad, that fatal weekend in Adelaide, in July this and young life. He even mentioned that he used to ISBN: 978-1489509062 year (2013). It was difficult to comprehend how sit under the street light to read his school books. He Book and order information: something like this could have happened. It wasn't didn't have a table and chair for his studies. There acceptable that he was no more.
were many times that he didn't have a pair of shoes Dr Umanand Prasad was born on 26 November to put on. He used to accompany his father to the Why speak when you can sing? Why not make education fun for the people you're serving? These are 1946. He did his primary and secondary schooling in market to sell vegetables.
the questions Darlene Keju asked as she launched her renowned Youth to Youth in Health program in the Labasa and his university entrance at Natabua High Thus he was able to feel and identify with the com- Marshall Islands. But the questions didn't end there.
School in Lautoka. He studied MBBS at Fiji School munity's needs and financial constraints. He knew Why let the young watch from the sidelines when you can bring them along for the ride? So she did, of Medicine (now known as the College of Medi- there were so many families out there, especially in fashioning a group of Marshallese educators from an age group who would have been cautioned to keep cine, Nursing and Health Sciences) in Suva for 2½ the west, with sons and daughters who excelled in their eyes open and their mouths closed. years after which he was awarded an ICCR Schol- their studies but did not stand any chance for entry Why settle for being a spectator when you might be able to change the world? Or at least one small arship to study medicine at Grant Medical College into the only medical school in Suva mainly due to piece of it? This book is the story of the transformation of a young woman who, from someone who once in Mumbai, India, where he studied for a further 4½ financial constraints. He strongly felt that these stu- knew little English, became an advocate for her people, the victims of the weapons of war. Darlene Keju years. He was a gold medalist in Anatomy. He did dents deserved a chance at their studies and their criticised the US government's response to its substantial nuclear legacy, while also proposing to establish his internship at JJ Hospital in Bombay. Thereafter, career and that is what he gave to the community, baseline health data that could be used as a basis for medical interventions.
he did his residency in Surgery at Lautoka hospital the people of Fiji, the students, by opening up a She excelled as an educational innovator, with far-reaching effects throughout her island nation. As she where he also took up teaching classes for nurs- lived and worked, Darlene didn't just touch lives, she moulded them, as the personal testimony in this book ing students in Surgery. Then he did his residency For Dr Prasad, the medical school was his heart in Obstetrics and Gynaecology at Lautoka hospital and soul. He breathed, it, lived it, worked hard at it. This book is the tale of a woman who saw Marshall Islanders as much more than victims of nuclear ir- where he again took classes in Obstetrics and Gy- UPSM was his pride. He spent five years in Fiji, full- radiation and colonial despoilment. Although no saint or flag-waver, Darlene shared with Mother Theresa naecology for nurses. He also completed postgrad- time from 2007 till 2011 and poured his heart and and Greg Mortenson (of Three Cups of Tea fame) the courage to dream daringly along with the commit- uate studies in Clinical Science in Australia. soul into the making of the school. He served as ment and patience to settle for one step - one family, one atoll - at a time.
He then took up general practice in Labasa for a the Dean of the school for the first 3 years. He saw Her legacy was a "can do" spirit and an insistence from the very beginning that it's up to her people to while before he was recruited to serve in Australia. the first two batches of students through their initial take the work a few steps further. You can't just sit in the back row and watch what's happening. Get up In the past 35 years of his having settled in Australia, years of study. He saw to the making of the UPSM and dance, she kept urging. You can help remake the world.
Dr Prasad's record of professional service was out- building, from the planning, day to day construction, standing. In 2009, he was awarded a distinguished up to the setting up of the building. He even land-service Award for outstanding dedicated service to scaped the gardens at UPSM and paid meticulous general practice in Australia. His academic and ca- attention to the planting of each and every tree. The reer details are lengthy, for he served in numerous whole process for him was not without pain or frus-positions and boards in Australia. tration. He stayed alone in Fiji while his family was He also served on numerous non-medical boards. back in Adelaide. Yet, he persevered. He gave a lot of time, effort and commitment to Dr Prasad created history by giving birth to this these activities purely out of love for his communi- medical school, which opened its doors to students ties and people. in January 2009. With great pride, it can be said that Dr Prasad had also written two books - an autobi- our first batch, the pioneer batch of students, will be ography, Mai Fiji and a book of verse, In the World graduating on 5 December 2013. Sadly, Dr Prasad, of Broken Hearted. the founding Dean, will not be with us to witness this Dr Umanand Prasad pledged a million dollars in historic occasion. Our sincere gratitude and heart- 2008 towards the setting up of a medical school at felt appreciation goes to Dr Prasad for his vision, University of Fiji. He was a visionary, a philanthro- his kindness and generosity, and his hard work. If it pist and a good businessman. wasn't for him, we wouldn't have students graduat- He had the qualities of being astute in his busi- ing as doctors at this university. May his soul rest in ness dealings and was very successful in his busi- peace. May our students, the school and the staff ness in Adelaide.
receive his blessings. May our medical school be But what most people remember him for, espe- blessed to continue to grow and reach its full poten- cially the staff and students of UPSM, was his kind- tial in providing medical education not only in Fiji but ness, generosity, his compassion and his strong de- to the Pacific region.
Vol 23 Number 1 2013 Fiji Medical Journal Vol 23 Number 1 2013 Fiji Medical Journal The UPSM Building
At the opening of the UPSM building in October 2009
At the opening of the UPSM building in October 2009 with Honourable Prime Minister, Commo-
dore Voreqe Bainimarama
Vol 23 Number 1 2013 Fiji Medical Journal Second Pacific Regional Pathology Symposium
The Faculty of Pathology and the Department of Health Sciences of the College of Medicine, Nursing & Health Sciences, FIJI NATIONAL UNIVERSITY, in collaboration with the International Academy of Pathology is hosting the Second Pacific Regional Pathology Symposium on Friday 25 and Saturday 26 April 2014. The event will be held at Pasifika auditorium; the organising chair is Asst. Prof. Abha Gupta, Department of Pathology. A number of international speakers have confirmed their participation. A detailed program of the symposium and speakers' profile will be available soon. Expressions of interest for participation are sought from members of the medical fraternity with an interest in pathology. Seats are limited and prior registration at nominal cost to cover catering expenses, is mandatory. To register - send your name, designation, location and contact details to the organising secretary Dr. Virisila Ciri, Senior Registrar Pathology ([email protected]). For enquiries, please contact: Dr. Abha Gupta: [email protected] Mob: 921 5131 A/Prof. Ponswamy Goundar: [email protected] A/Prof Kamal Kishore: [email protected] Mob: 926 7466 Dr. Virisila Ciri: Mob: 9231187

Source: http://www.cmnhs.fnu.ac.fj/fmj/images/Publications/FMJ_Vol_23_Number_1_2013.pdf