The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease

Challenges in Infective Endocarditis

Infective endocarditis is defined by a focus of infection within the heart and is a feared disease across the field of cardiology. It is frequently acquired in the health care setting, and more than one-half of cases now occur in patients without known heart disease. Despite optimal care, mortality approaches 30% at 1 year. The challenges posed by infective endocarditis are significant. It is heterogeneous in etiology, clinical manifestations, and course. Staphylococcus aureus, which has become the predominant causative organism in the developed world, leads to an aggressive form of the disease, often in vulnerable or elderly patient populations. There is a lack of research infrastructure and funding, with few randomized controlled trials to guide practice. Longstanding controversies such as the timing of surgery or the role of antibiotic prophylaxis have not been resolved. The present article reviews the challenges posed by infective endocarditis and outlines current and future strategies to limit its impact.

Heart Disease and Pregnancy

Cardiac disease remains a major cause of morbidity and mortality in pregnant and post-partum women, although progress has been made, with specialist joint obstetric-cardiology clinics providing an integrated, safe and personalised service to these women. As a result, fewer non-specialist cardiologists are managing women in pregnancy with cardiovascular disease. The aim of this review is to provide a brief overview of current knowledge and practice in the field, with an emphasis on the major physiological changes which occur during pregnancy, focussing on progress through the trimesters, clinical assessment in pregnancy, management of delivery (concentrating on managed vaginal delivery), drug treatment, key conditions and risk assessment. The latter factor is particularly important in terms of being able to identify high-risk women earlier and to counsel them appropriately. Pregnant women with cardiovascular conditions can, with appropriate knowledge and counselling, be managed safely in specialist multidisciplinary services, but there is a need for cardiologists to understand the key changes and risks involved in pregnancy, delivery and the post-partum period.

Paediatric rheumatology clinic population in Southeast Asia: are we different?

Objectives

To examine the descriptive epidemiology of the patient population referred to paediatric rheumatology centres (PRCs) in Southeast Asia (SEA) and to compare the frequency of conditions encountered with other PRC populations.

Methods

A web-based Registry for Childhood Onset Paediatric Rheumatic Diseases was established in 2009 and seven PRCs in four SEA countries, where paediatric rheumatologists are available, participated in a prospective 24 month data collection (43 months for Singapore).

Results

The number of patients analysed was 4038 (788 from Malaysia, 711 from the Philippines, 1943 from Singapore and 596 from Thailand). Over 70% of patients evaluated in PRCs in Malaysia, the Philippines and Thailand had rheumatic diseases (RDs), as compared with one-half of the proportion seen in Singaporean PRCs, which was similar to the Western PRC experience. Among RDs diagnosed (n = 2602), JIA was the most common disease encountered in Malaysia (41%) and Thailand (61%) as compared with systemic vasculitides in the Philippines (37%) and Singapore (35%) among which Henoch-Schönlein purpura was the most prevalent. SLE and related diseases were more common, but idiopathic pain syndrome and abnormal immunological laboratory tests were rarer than those seen in the West. JIA subtype distributions were different among countries. Among non-RDs (n = 1436), orthopaedic and related conditions predominated (21.7-59.4%).

Conclusion

The frequencies of RDs seen by SEA PRCs were different from those in the West. Systemic vasculitides and SLE were common in addition to JIA. Paediatric rheumatologist availability and healthcare accessibility partially explain these observed discrepancies.

DNA methylation dysregulations in rheumatic heart valve disease

Background

The epigenetic changes underlying the development of rheumatic heart valve disease (RHVD) remain incompletely understood. Limited evidence suggests that abnormal DNA methylation might be involved in the pathogenesis of RHVD. In the present study, we evaluated the DNA methylation dysregulations from myocardial tissue in RHVD patients systematically.

Methods

Right atrial myocardial tissue obtained from rheumatic valvular patients who had undergone valve replacements surgery (n = 73) and were compared to healthy controls (n = 4). the promoter methylation level of Intercellular adhesion molecule-1 (ICAM-1) gene and its correlation with ICAM-1 mRNA expression level, the global DNA methylation level and its correlation with age and mRNA expression level of DNA methyltransferase (DNMT) genes were detected.

Results

The ICAM-1 mRNA expression was increased (healthy control vs. NHYA III, 0.70 ± 0.19 vs. 4.38 ± 3.19, p = 0.011; NYHA IIvs. NHYA III, 2.60 ± 1.99 vs. 4.38 ± 3.19, p = 0.008) and the ICAM-1 gene was hypomethylated in RHVD patients (healthy controls vs. NYHA II, 0.120 ± 0.011 vs. 0.076 ± 0.057, p = 0.039; healthy control vs. NHYA III, 0.120 ± 0.011 vs. 0.041 ± 0.022, p < 0.001; NYHA IIvs. NHYA III, 0.076 ± 0.057 vs. 0.041 ± 0.022, p < 0.001). Meanwhile, The ICAM-1 mRNA expression level has negative correlation with the mean methylation level in the promoter region of ICAM-1 gene (r = −0.459, p < 0.001). The global DNA methylation levels was significantly increased in RHVD patients than in healthy controls (healthy control vs. NHYA III, 0.77 ± 0.28 vs. 2.09 ± 1.20, p = 0.017; NYHA IIvs. NHYA III, 1.57 ± 0.78 vs. 2.09 ± 1.20, p = 0.040) and had positive correlation with age (r = 0.326, p = 0.005), especially for older age group (≥ 60 years). DNMT1 likely plays an essential role in the DNA dysregulations in RHVD patients.

Conclusions

Our analysis revealed that DNA methylation dysregulations may be relevant in the pathogenesis of RHVD.

Acute Rheumatic Fever: Global Persistence of a Preventable Disease

The persistence of acute rheumatic fever continues to be seen globally. Once thought to be eradicated in various parts of the world, the disease came back with a vengeance secondary to a lack of diligence on the part of providers. Today, the global burden of group A streptococcal infection, the culprit of the numerous sequelae manifested in acute rheumatic fever, is considerable. Although a completely preventable disease, rheumatic fever continues to exist. It is a devastating disease that involves long-term, multisystem treatment and monitoring for patients who were unsuccessful at eradicating the precipitating group A streptococcal infection. Prevention is the key to resolving the dilemma of the disease's global burden, yet the method to yield its prevention still remains unknown. Thus, meticulous attention to implementing proper treatment is the mainstay and remains a top priority.

Cardiovascular disease in Africa: epidemiological profile and challenges

From a global perspective, the large and diverse African population is disproportionately affected by cardiovascular disease (CVD). The historical balance between communicable and noncommunicable pathways to CVD in different African regions is dependent on external factors over the life course and at a societal level. The future risk of noncommunicable forms of CVD (predominantly driven by increased rates of hypertension, smoking, and obesity) is a growing public health concern. The incidence of previously rare forms of CVD such as coronary artery disease will increase, in concert with historically prevalent forms of disease, such as rheumatic heart disease, that are yet to be optimally prevented or treated. The success of any strategies designed to reduce the evolving and increasing burden of CVD across the heterogeneous communities living on the African continent will be dependent upon accurate and up-to-date epidemiological data on the cardiovascular profile of every major populace and region. In this Review, we provide a contemporary picture of the epidemiology of CVD in Africa, highlight key regional discrepancies among populations, and emphasize what is currently known and, more importantly, what is still unknown about the CVD burden among the >1 billion people living on the continent.

The association between systemic lupus erythematosus and valvular heart disease: an extensive data analysis

BACKGROUND

Association between antiphospholipid syndrome in systemic lupus erythematosus (SLE) and valvular heart disease (VHD) is well reported, but relatively few studies have been carried out to establish the linkage between VHD and SLE itself. We aimed to investigate link between VHD and SLE and to evaluate the association of diverse factors with VHD among these patients in a large-scale population-based study.

MATERIALS AND METHODS

We used the databases of the largest state-mandated health service organization in Israel. All SLE patients were included (n = 5018) as well as their age and sex-matched controls (n = 25 090), creating a cross-sectional population-based study. Medical records of all subjects were analysed for documented VHD and the presence of antiphospholipid antibodies (aPLs). A logistic regression model was carried out to evaluate the diverse factors including SLE and aPLs as independent risk factors for VHD.

RESULTS

Valvular heart disease were found to be more frequent among SLE group when compared to controls (aortic stenosis, 1·08% vs. 0·35% respectively, P < 0·001; aortic insufficiency, 1·32% vs. 0·29% respectively, P < 0·001; mitral stenosis, 0·74% vs. 0·21% respectively, P < 0·001; mitral insufficiency, 1·91% vs. 0·39% respectively, P < 0·001). Male sex, hypertension, aPLs and SLE were found to be significant independent risk factors for VHD.

CONCLUSION

All VHD are more prevalent among SLE patients when compared to controls. SLE and aPLs are independent risk factor for VHD (OR of 2·46 and 1·7, respectively). Physicians must be aware of such significant association, and routine echocardiography should be considered in SLE patients regardless of their aPL status.

Clinical presentation and outcomes of patients with acute rheumatic fever and rheumatic heart disease seen at a tertiary hospital setting in Port Elizabeth, South Africa

Background:

The incidence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) has waned in Western countries, however that is not the situation in developing nations.

Methods:

Records were reviewed of patients from the Eastern Cape municipal districts who presented to the Paediatric Cardiology Unit with ARF and RHD from January 2008 to August 2015.

Results:

Total of 56 patients with ARF/RHD was reviewed. The majority of patients (n = 52) presented for the first time with RHD. Four patients presented with ARF and two had recurrent ARF. Six patients presented with a combination of RHD and congenital heart disease. Twenty-three patients were operated on for chronic rheumatic valve disease, with good outcomes.

Conclusion:

The true burden of ARF/RHD is unknown in the Eastern Cape. Prospective studies are needed to accurately determine the prevalence of RHD in this province.

Group A Streptococcus, Acute Rheumatic Fever and Rheumatic Heart Disease: Epidemiology and Clinical Considerations

OPINION STATEMENT

Early recognition of group A streptococcal pharyngitis and appropriate management with benzathine penicillin using local clinical prediction rules together with validated rapi-strep testing when available should be incorporated in primary health care. A directed approach to the differential diagnosis of acute rheumatic fever now includes the concept of low-risk versus medium-to-high risk populations. Initiation of secondary prophylaxis and the establishment of early medium to long-term care plans is a key aspect of the management of ARF. It is a requirement to identify high-risk individuals with RHD such as those with heart failure, pregnant women, and those with severe disease and multiple valve involvement. As penicillin is the mainstay of primary and secondary prevention, further research into penicillin supply chains, alternate preparations and modes of delivery is required.

Rheumatic fever with severe carditis: still prevalent in the South West Pacific

Rheumatic heart disease (RHD) has a worldwide prevalence of 33 million cases and 270 000 deaths annually, making it the most common acquired heart disease in the world. There is a disparate global burden in developing countries. This case report aims to address the minimal RHD coverage by the international medical community. A Tahitian boy aged 10 years was diagnosed with advanced heart failure secondary to RHD at a local clinic. Previous, subtle symptoms of changes in handwriting and months of fever had gone unrecognised. Following a rapid referral to the nearest tertiary centre in New Zealand, urgent cardiac surgery took place. He returned home facing lifelong anticoagulation. This case highlights the RHD burden in Oceania, the limited access to paediatric cardiac services in countries where the RHD burden is greatest and the need for improved awareness of RHD by healthcare professionals, and the general public, in endemic areas.

Infective Endocarditis in Low- and Middle-Income Countries

Infective endocarditis (IE) is a rare, life-threatening disease with a mortality rate of 25% and significant debilitating morbidities. Although much has been reported on contemporary IE in high-income countries, conclusions on the state of IE in low- and middle-income countries (LMICs) are based on studies conducted before the year 2000. Furthermore, unique challenges in the diagnosis and management of IE persist in LMICs. This article reviews IE studies conducted in LMICs documenting clinical experiences from the year 2000 to 2016. Presented are the causes of IE, management of patients with IE, and prevailing challenges in diagnosis and treatment of IE in LMICs.

Guidelines for the secondary prevention of rheumatic heart disease: Endorsed by Saudi Pediatric Infectious Diseases Society (SPIDS)

Rheumatic fever is a rare yet serious condition develop as a consequence of throat infection caused by Streptococcus pyogenes. It is the leading cause for rheumatic heart disease. Rheumatic heart disease is a worldwide public health concern. It is a chronic condition that results in carditis, irreversible valve damage and heart failure in children and young adults living in low-income countries. The age of onset peaks between 5 and 15 years. Approximately, 3% of patients with untreated acute streptococcal sore throats develop rheumatic fever.

Rheumatic fever and rheumatic heart disease can be prevented with appropriate antibiotics administration to prevent the progression of valve damage. The current use of primary and secondary prevention antibiotics in Saudi Arabia is not known. Therefore, this clinical practice guideline is developed, based on the best available evidence, to promote appropriate antibiotics secondary prophylaxis use for prevention of rheumatic heart disease.

"HLA-G 3'UTR gene polymorphisms and rheumatic heart disease: a familial study among South Indian population"

BACKGROUND

Rheumatic heart disease (RHD) is an autoimmune disease where cross reactive CD4⁺ T cells are involved in the pathogenesis of valvular damage. Human Leukocyte Antigen-G (HLA-G), an immunosuppressive molecule playing a crucial role in the inhibition of T cell response is associated with the pathogenesis of various autoimmune and inflammatory diseases. Genetic polymorphisms within the 3'untranslated region (UTR) of HLA-G influences its expression and thus disease pathogenesis. Hence, the present study aims to unravel the association of 14 bp Ins/Del (rs66554220) and +3142 C/G (rs1063320) polymorphisms in 3' UTR of HLA-G with RHD.

METHODS

This familial study consists of 99 RHD families (99 RHD patients, 140 parents and 126 healthy siblings). The 14 bp Ins/Del and +3142 C/G polymorphisms were evaluated by PCR using sequence specific primers and its transmission disequilibrium (TD) was tested by TD test in 70 trio families.

RESULTS

The frequency of +3142 C/C genotype was high in patients with combined valvular lesions (CVL) (OR = 5.88; p_c = 0.012) and pooled RHD patients (P: OR = 2.76; p = 0.043; p_c = 0.076) when compared to healthy siblings. Under the additive (OR = 5.50; p_c = 0.026) and recessive genetic model (OR = 5.88; p_c = 0.012), the +3142 C/C genotype was significantly associated with CVL in patients.

CONCLUSION

The results suggest that the +3142 C/C genotype may be associated with minor risk for the development of RHD and is more likely to influence the severity of the disease.

Acute rheumatic fever: clinical profile in children in western Ukraine

Acute rheumatic fever (ARF) may have different clinical manifestations in different countries according to the genetic predisposition, prevalence of rheumatogenic strains, social and economic conditions. The purpose of this study was to determine the clinical characteristics of ARF in Western Ukraine and to improve the detection of the cases. A retrospective analysis of 85 medical clinical cases of in-hospital patients aged from 4 to 17 years old was performed. The cases covered patients who underwent treatment in the City Children's Hospital of Ternopil during 2000 and 2013 with the ARF diagnosis, which was established according to Jones criteria. 65.9% of the ARF patients were admitted to the hospital from October to March. Fever (65.9%) and joint syndrome (78.8%) were the most common causes for admission to the medical care. The admission diagnosis was wrong in 34 (40.0%) children who underwent the treatment. The most frequent major Jones criteria of ARF were carditis (84.7%) and polyarthritis (54.1%). Chorea was significantly less common than carditis (р < 0,001). The adequate treatment of the preceding streptococcal infection was administered in 25 children (53.2%).

CONCLUSIONS

The significant incidence of misdiagnoses in the ARF children during admission to the hospital, especially the interpretation of joint syndrome, indicates that physicians need an extra awareness. The lack of specific clinical signs of rheumatic carditis makes it a diagnostic challenge. The revised Jones criteria (2015) for the diagnosis of ARF can improve carditis detection. The adequate treatment of the preceding streptococcal infection may prevent ARF. Abbreviations: ARF = acute rheumatic fever.

Acute rheumatic fever outbreak in southern central European country

A decline in the incidence of acute rheumatic fever (ARF) in developed countries over the past century can be attributed to the improved public hygiene and to widespread use of antibiotics. ARF seemed to be a rare disease in southern central European country, Slovenia, up to 2010 when we noticed an increase in the number of patients with ARF. In order to assess the current incidence of ARF, we performed a retrospective study of all patients with ARF treated at the University Children's Hospital Ljubljana from January 2008 until the end of December 2014. In a period of 7 years, 19 patients with ARF were identified. The estimated annual incidence of ARF during the study period was 1.25 cases per 100,000 children. Carditis was present in all patients, arthritis in 37 % and Sydenham chorea in 32 %.

CONCLUSION

Recent ARF outbreak in Slovenia revealed that this disease is still present in southern central Europe with an estimated annual incidence of 1.25 cases per 100,000 children. Unrecognized or inadequately treated ARF could be the cause of acquired heart disease and must be even nowadays included among the differential diagnoses in a febrile child with arthritis, heart murmur or movement disorder. What is Known: • Acute rheumatic fever (ARF) is diagnosed based on the major and minor Jones Criteria. • A decline in the incidence of ARF in developed countries over the past century can be attributed to the improved public hygiene and to widespread use of antibiotics. What is New: • In the last decade, an increase in the incidence of ARF was observed in Slovenia which has a central European geographic position. • Our paper highlights the importance of including ARF in the differential diagnosis of a febrile child with arthritis/arthralgia and/or heart murmur and/or acute chorea.

Descriptive Analysis of In Vitro Cutting of Swine Mitral Cusps: Comparison of High-Power Laser and Scalpel Blade Cutting Techniques

BACKGROUND AND OBJECTIVES

The most common injury to the heart valve with rheumatic involvement is mitral stenosis, which is the reason for a big number of cardiac operations in Brazil. Commissurotomy is the traditional technique that is still widely used for this condition, although late postoperative restenosis is concerning. This study's purpose was to compare the histological findings of porcine cusp mitral valves treated in vitro with commissurotomy with a scalpel blade to those treated with high-power laser (HPL) cutting, using appropriate staining techniques.

MATERIALS AND METHODS

Five mitral valves from healthy swine were randomly divided into two groups: Cusp group (G1), cut with a scalpel blade (n = 5), and Cusp group (G2), cut with a laser (n = 5). G2 cusps were treated using a diode laser (λ = 980 nm, power = 9.0 W, time = 12 sec, irradiance = 5625 W/cm², and energy = 108 J).

RESULTS

In G1, no histological change was observed in tissue. A hyaline basophilic aspect was focally observed in G2, along with a dark red color on the edges and areas of lower birefringence, when stained with hematoxylin-eosin, Masson's trichrome, and Sirius red. Further, the mean distances from the cutting edge in cusps submitted to laser application and stained with Masson's trichrome and Sirius red were 416.7 and 778.6 μm, respectively, never overcoming 1 mm in length.

CONCLUSIONS

Thermal changes were unique in the group submitted to HPL and not observed in the cusp group cut with a scalpel blade. The mean distance of the cusps' collagen injury from the cutting edge was less than 1 mm with laser treatment. Additional studies are needed to establish the histological evolution of the laser cutting and to answer whether laser cutting may avoid valvular restenosis better than blade cutting.

Approaches to Sustainable Capacity Building for Cardiovascular Disease Care in Kenya

Cardiovascular diseases are approaching epidemic levels in Kenya and other low- and middle-income countries without accompanying effective preventive and therapeutic strategies. This is happening in the background of residual and emerging infections and other diseases of poverty, and increasing physical injuries from traffic accidents and noncommunicable diseases. Investments to create a skilled workforce and health care infrastructure are needed. Improving diagnostic capacity, access to high-quality medications, health care, appropriate legislation, and proper coordination are key components to ensuring the reversal of the epidemic and a healthy citizenry. Strong partnerships with the developed countries also crucial.

Correlation of angiotensin I-converting enzyme gene insertion/deletion polymorphism with rheumatic heart disease: a meta-analysis

Rheumatic heart disease (RHD) is a serious cardiovascular disorder worldwide. Several articles have reported the effect of angiotensin I-converting enzyme gene insertion/deletion (ACE I/D) polymorphism in RHD risk. However, the results still remain inconsistent. The objective of the present study was to assess more precise estimations of the relationship between ACE I/D variant and RHD susceptibility. Relevant case–control studies published between January 2000 and 2016 were searched in the electronic databases. The odds ratio (OR) with its 95% confidence interval (CI) was employed to calculate the strength of the effect. A total of nine articles were retrieved, including 1333 RHD patients and 1212 healthy controls. Overall, our result did not detect a significant association between ACE I/D polymorphism and RHD risk under each genetic model (P > 0.05). Subgroup analysis by ethnicity showed no positive relationship in Asians as well (P > 0.05). With respect to the severity of RHD, our result found that the frequency differences between mitral valve lesion (MVL), combined valve lesion (CVL) and healthy controls were not significantly different. Furthermore, no significant association was found between female, male RHD patients and the controls regarding to the ACE I/D polymorphism. In conclusion, our result indicated that ACE I/D polymorphism might not be a risk factor for RHD progression based on the existing research results. Additional well-designed studies with larger samples are still needed to confirm these findings.

Effect of zinc deficiency on mouse renal interstitial fibrosis in diabetic nephropathy

There is emerging evidence that tubulointerstitial fibrosis is the final common pathway of the majority of chronic progressive renal diseases, including diabetic nephropathy (DN). Zinc, an essential dietary element, has been suggested to be important for a number of protein functions during fibrosis in vivo and in vitro. However, the effect of zinc deficiency (ZnD) on renal interstitial fibrosis in DN remains unclear. The present study investigated the effect and the underlying mechanisms of ZnD on renal interstitial fibrosis during DN using an streptozotocin‑induced model of diabetes with immunofluorescence staining and western blot analysis. The present study identified that dietary zinc restriction significantly decreased zinc concentrations in the plasma and mouse kidney. ZnD enhanced albuminuria and extracellular matrix protein expression, associated with diabetic renal interstitial fibrosis by activation of renal interstitial fibroblasts and regulation of the expression of fibrosis‑associated factors, which may be mediated by the activation of fibroblasts via the TGF‑β/Smad signaling pathway. The data indicates that ZnD serves an important role in the pathogenic mechanisms of renal interstitial fibrosis during the development of DN.

Cardiac surgery in Africa: a thirty-five year experience on open heart surgery in Cote d'Ivoire

BACKGROUND

Few centers for open heart surgery (OHS) are in Sub-Saharan Africa. Lack of OHS results is also noted. By reporting our African experience on OHS, the aim of this study was to fill the gap.

METHODS

It is a retrospective study on 2,612 patients who were subject to an OHS between 1978 and 2013. Data were collected from demographical, clinical, investigative studies, surgical and outcomes parameters.

RESULTS

There were 1,475 cases of rheumatic heart diseases (RHD), 126 endomyocardial fibrosis (EMF), 741 congenital heart diseases (CHDs) and 270 various affections. Related to rheumatic valvular surgery we enumerated 1,175 monovalvular (mitral n=778, aortic n=336, tricuspid n=61); 280 bivalvular (mitral + aortic n=150, mitral + tricuspid n=130) and 20 trivalvular. For RHD, average age was 26±10.1 years (4-69 years) and 60% of our patients presented a functional class III or IV according to New York Heart Association (NYHA) classification. A total of 1,481 valvular replacements (bioprostheses n=489, mechanical prostheses n=992) and 445 valvular repair were carried out with a global and late mortality surgery respectively at 7% and 8%. One hundred and twenty-six [126] cases of EMF with right sided form 39, left sided form 40, and bilateral form 47 were colligated. Average age was 12±0.6 years (2-15 years). All patients with EMF underwent surgery; an endocardectomy in all patients combined with valvular reconstruction (n=36) or valvular replacement (n=90) was carried out with a hospital mortality at 16% (n=20). Concerning CHD, the most frequent were ventricular septal defect (VSD) (n=240), atrial septal defect (ASD) (n=200), partial atrio-ventricular sepal defect (n=30) and tetralogy of Fallot (T4F) (n=220), a total correction was performed for those CHD with an early mortality at 6.4% (n=44).

CONCLUSIONS

OHS in Cote d'Ivoire was successfully performed in most of our patients, the spectrum of acquired valvular heart diseases and CHDs in our country is similar to others in Sub-Saharan Africa.

Predictors of recurrence in Sydenham's chorea: Clinical observation from a single center

OBJECTIVE

Sydenham's chorea is the most common cause of acquired chorea in children and is the major manifestation for acute rheumatic fever. Despite being known as a benign, self-limiting condition, recurrences and persistence of symptoms can be seen. In this study, we aimed to evaluate retrospectively the clinical and laboratory features of patients with Sydenham's chorea and the rate and the course of recurrences, and to assess the risk of recurrences.

METHODS

The study was a retrospective study conducted in a tertiary hospital. Patients with Sydenham's chorea who were admitted to our outpatient clinics between January 2013 and June 2015 were included. Both newly diagnosed and follow-up patients were enrolled during this period. We retrospectively reviewed the medical charts of the patients.

RESULTS

There were 90 patients with female predominance. The mean age of onset was 11±2.4years. Complete remission was maintained in 77 patients (85.6%) at 1-6months and 4 patients had symptoms at more than 12months. Patients were followed for 6months to 9years. The recurrence rate was 16%. When we compared recurrent patients with the non-recurrent group, complete remission in 6months, the presence of persistent chorea, and regular use of prophylaxis were significantly different between the 2 groups.

CONCLUSIONS

Sydenham's chorea is still an important health problem and has high morbidity in patients with recurrent and persistent chorea. The irregular usage of antibiotic prophylaxis, failure to achieve remission within 6months, and prolongation of symptoms for more than 1year are risk factors for recurrence of chorea.

Timing of Surgical Intervention for Aortic Regurgitation

OPINION STATEMENT

Aortic regurgitation is a frequently encountered condition, in which traditional measurements of severity have proven to be of limited value in identifying those who would be best served by aortic valve replacement. Novel methods of assessing severity are vital, particularly as an entirely new paradigm of aortic regurgitation has surfaced, with the advent of transcatheter aortic valve replacement (TAVR), and the adverse events that are being observed with varying degrees of aortic regurgitation. With that in mind, a comprehensive assessment of aortic regurgitation should now include indexed left ventricular systolic volumes and a comprehensive assessment of right ventricular function, in addition to the quantitative measures that are currently recommended. Cardiac MRI also provides valuable information and should be strongly considered, particularly in challenging cases. The incremental value of additional echocardiographic parameters such as strain imaging, speckle tracking imaging, and tissue Doppler imaging remains unclear, and evidence for their utility is not, as yet, compelling. However, the field of aortic regurgitation assessment has been reinvigorated by the prevalence of paravalvular regurgitation post-TAVR, and many of the abovementioned parameters may need to be re-visited so that we can more accurately determine prognosis and risk stratify patients in a more reliable and evidence-based manner.

Surgical Repair of Mitral Valve Disease in Children: Perioperative Changes in Respiratory Function

OBJECTIVE

To assess the profile of changes in airway and respiratory tissue mechanics within a follow-up study performed in children with mitral valve disease, before and after surgical valve repair.

DESIGN

Perioperative measurements in a prospective, consecutive cross-sectional study.

SETTING

University hospital, tertiary care teaching hospital

PARTICIPANTS

The study comprised 24 children with congenital or post-rheumatic mitral valve insufficiency.

INTERVENTIONS

Input impedance of the respiratory system during spontaneous breathing was measured before and 5 days and 3 weeks after mitral valve surgery. In addition, airway and respiratory tissue mechanics and pulmonary arterial pressure were assessed with the patient under general anesthesia preoperatively and immediately postoperatively. Respiratory tissue elastance and changes in airway measurements were estimated from forced oscillatory impedance data by fitting an appropriate model.

MEASUREMENT AND MAIN RESULTS

Relating airway and respiratory tissue mechanics to previously established reference values obtained in age-matched healthy control patients revealed abnormal respiratory function (135±6.2% and 148±13% in respiratory elastance and resistance, respectively; p<0.001). Improvement in the airway properties was observed immediately after surgery (-15.2±3.4%; p<0.005) and lasted for the study period (-19±4.1%; p<0.001). Respiratory tissue elastance, which correlated preoperatively to the diastolic pulmonary arterial pressure, decreased only 5 days postoperatively (-20.6±4.1%; p<0.005). However, there was no evidence of a clear, immediate effect of surgery on the tissue mechanical parameters measured intraoperatively despite a decrease in diastolic pulmonary pressure.

CONCLUSIONS

Mitral valve disease in children leads to abnormal airway and respiratory tissue mechanics. Even though surgical repair of mitral insufficiency alleviates abnormal airway function, residual lung tissue stiffening may persist even weeks after the surgery, contributing to a sustained impairment in lung function.

Percutaneous and minimally invasive approaches to mitral valve repair for severe mitral regurgitation-new devices and emerging outcomes

Mitral valve disease is common in the United States and around the world, and if left untreated, increases cardiovascular morbidity and mortality. Mitral valve repair is technically more demanding than mitral valve replacement. Mitral valve repair should be considered the first line of treatment for mitral regurgitation in younger patients, mitral valve prolapse, annular dilatation, and with structural damage to the valve. Several minimally invasive percutaneous treatment options for mitral valve repair are available that are not restricted to conventional surgical approaches, and may be better received by patients. A useful classification system of these approaches proposed by Chiam and Ruiz is based on anatomic targets and device action upon the leaflets, annulus, chordae, and left ventricle. Future directions of minimally invasive techniques will include improving the safety profile through patient selection and risk stratification, improvement of current imaging and techniques, and multidisciplinary education.

Rapid antigen detection test for group A streptococcus in children with pharyngitis

BACKGROUND

Group A streptococcus (GAS) accounts for 20% to 40% of cases of pharyngitis in children; the remaining cases are caused by viruses. Compared with throat culture, rapid antigen detection tests (RADTs) offer diagnosis at the point of care (within five to 10 minutes).

OBJECTIVES

To determine the diagnostic accuracy of RADTs for diagnosing GAS in children with pharyngitis. To assess the relative diagnostic accuracy of the two major types of RADTs (enzyme immunoassays (EIA) and optical immunoassays (OIA)) by indirect and direct comparison.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, Web of Science, CDSR, DARE, MEDION and TRIP (January 1980 to July 2015). We also conducted related citations tracking via PubMed, handsearched reference lists of included studies and relevant review articles, and screened all articles citing included studies via Google Scholar.

SELECTION CRITERIA

We included studies that compared RADT for GAS pharyngitis with throat culture on a blood agar plate in a microbiology laboratory in children seen in ambulatory care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, assessed full texts for inclusion, and carried out data extraction and quality assessment using the QUADAS-2 tool. We used bivariate meta-analysis to estimate summary sensitivity and specificity, and to investigate heterogeneity across studies. We compared the accuracy of EIA and OIA tests using indirect and direct evidence.

MAIN RESULTS

We included 98 unique studies in the review (116 test evaluations; 101,121 participants). The overall methodological quality of included studies was poor, mainly because many studies were at high risk of bias regarding patient selection and the reference standard used (in 73% and 43% of test evaluations, respectively). In studies in which all participants underwent both RADT and throat culture (105 test evaluations; 58,244 participants; median prevalence of participants with GAS was 29.5%), RADT had a summary sensitivity of 85.6%; 95% confidence interval (CI) 83.3 to 87.6 and a summary specificity of 95.4%; 95% CI 94.5 to 96.2. There was substantial heterogeneity in sensitivity across studies; specificity was more stable. There was no evidence of a trade-off between sensitivity and specificity. Heterogeneity in accuracy was not explained by study-level characteristics such as whether an enrichment broth was used before plating, mean age and clinical severity of participants, and GAS prevalence. The sensitivity of EIA and OIA tests was comparable (summary sensitivity 85.4% versus 86.2%). Sensitivity analyses showed that summary estimates of sensitivity and specificity were stable in low risk of bias studies.

AUTHORS' CONCLUSIONS

In a population of 1000 children with a GAS prevalence of 30%, 43 patients with GAS will be missed. Whether or not RADT can be used as a stand-alone test to rule out GAS will depend mainly on the epidemiological context. The sensitivity of EIA and OIA tests seems comparable. RADT specificity is sufficiently high to ensure against unnecessary use of antibiotics. Based on these results, we would expect that amongst 100 children with strep throat, 86 would be correctly detected with the rapid test while 14 would be missed and not receive antibiotic treatment.

An epidemiological study to assess the true incidence and prevalence of rheumatic heart disease and acute rheumatic fever in New Caledonian school children

AIM

To provide in New Caledonian school children (i) the prevalence of rheumatic heart disease (RHD) detected by annual screening program using new World Heart Federation diagnostic criteria; (ii) the point prevalence of acute rheumatic fever (ARF); and (iii) to investigate socio-demographic risk factors associated with RHD.

METHODS

This study linked data from national ARF/RHD programs by combining ARF incidence data from the register with RHD prevalence data from echocardiographic screening data for a single age year of the population for overall point prevalence ARF/RHD rates. For the analysis, cases of echocardiographic detection of RHD are presumed to be synonymous with undiagnosed ARF. All results were weighted to minimise the bias introduced from absent pupils of each annual screening program. Incidence and prevalence were age-standardised to the WHO World Standard Population. Each 2013 cumulative prevalence of definite and borderline RHD was studied using a multivariate logistic regression adjusted for socio-demographic factors.

RESULTS

The overall age-standardised incidence of clinical and undiagnosed ARF (i.e. echocardiographic-detected RHD) was combined as point prevalence and estimated to be 99/10 000 cases in 2012 and 114/10 000 cases in 2013. This included 40/10 000 prevalent cases of asymptomatic RHD detected by screening each year. Being Melanesian, OR 23.2 (95% CI: 3.4-157.3), or Polynesian, OR 21.5 (95% CI: 2.9-157.7), was associated with a higher prevalence of having definite RHD compared with being Caucasian. Being a girl was associated with a higher risk of having borderline RHD, OR 1.9 (95% CI: 1.03-3.3).

CONCLUSION

Without echocardiographic screening, ARF/RHD burden is substantially underestimated.

Brief Report: Prevalence of Latent Rheumatic Heart Disease Among HIV-Infected Children in Kampala, Uganda

Rheumatic heart disease (RHD) remains highly prevalent in resource-constrained settings around the world, including countries with high rates of HIV/AIDS. Although both are immune-mediated diseases, it is unknown whether HIV modifies the risk or progression of RHD. We performed screening echocardiography to determine the prevalence of latent RHD in 488 HIV-infected children aged 5-18 in Kampala, Uganda. The overall prevalence of borderline/definite RHD was 0.82% (95% confidence interval: 0.26% to 2.23%), which is lower than the published prevalence rates of 1.5%-4% among Ugandan children. There may be protective factors that decrease the risk of RHD in HIV-infected children.

Access to Medications for Cardiovascular Diseases in Low- and Middle-Income Countries

Cardiovascular diseases (CVD) represent the highest burden of disease globally. Medicines are a critical intervention used to prevent and treat CVD. This review describes access to medication for CVD from a health system perspective and strategies that have been used to promote access, including providing medicines at lower cost, improving medication supply, ensuring medicine quality, promoting appropriate use, and managing intellectual property issues. Using key evidence in published and gray literature and systematic reviews, we summarize advances in access to cardiovascular medicines using the 5 health system dimensions of access: availability, affordability, accessibility, acceptability, and quality of medicines. There are multiple barriers to access of CVD medicines, particularly in low- and middle-income countries. Low availability of CVD medicines has been reported in public and private healthcare facilities. When patients lack insurance and pay out of pocket to purchase medicines, medicines can be unaffordable. Accessibility and acceptability are low for medicines used in secondary prevention; increasing use is positively related to country income. Fixed-dose combinations have shown a positive effect on adherence and intermediate outcome measures such as blood pressure and cholesterol. We have a new opportunity to improve access to CVD medicines by using strategies such as efficient procurement of low-cost, quality-assured generic medicines, development of fixed-dose combination medicines, and promotion of adherence through insurance schemes that waive copayment for long-term medications. Monitoring progress at all levels, institutional, regional, national, and international, is vital to identifying gaps in access and implementing adequate policies.

The transcatheter valve technology pipeline for treatment of adult valvular heart disease

The transcatheter valve technology pipeline has started as simple balloon valvuloplasty for the treatment of stenotic heart valves and evolved since the year 2000 to either repair or replace heart valves percutaneously with multiple devices. In this review, the present technology and its application are illuminated and a glimpse into the near future is dared from a physician's perspective.

Pattern of acquired heart diseases among children seen in Sokoto, North‑Western Nigeria

BACKGROUND

Acquired heart diseases (AHDs) are serious but largely preventable diseases. They are highly prevalent in developing countries where poverty, illiteracy, and poor socioeconomic conditions still pose a significant challenge. The prevalence and pattern of AHD among children have not been previously documented within the study area.

OBJECTIVES

To determine the pattern and outcome of AHDs among children in Sokoto, North-Western Nigeria.

SUBJECTS AND METHODS

A prospective study conducted at the Pediatric Department of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria from 1st July 2009 to 30th June 2014. Data from all the subjects with AHD were analyzed using Statistical Package for Social Sciences.

RESULTS

Of the 3810 children, 110 (2.9%) children were diagnosed with AHD over the study period. The mean age of the subjects was 10.4±3.4 years with M: Fratio of 1.2:1. Rheumatic heart disease (RHD) was the most common AHD seen in 47 (42.7%) patients, followed by dilated cardiomyopathy/myocarditis in 36 (32.7%) and pericardial effusion in 12 (10.9%) patients. Endomyocardial fibrosis was seen in 7 (6.4%) patients while infective endocarditis and Kawasaki disease occurred in 6 (5.5%) and 2 (1.8%) patients respectively. Mortality rate was 17.3%. Commonly observed co-morbidities included heart failure, bronchopneumonia, and pulmonary hypertension.

CONCLUSION

The pattern of AHD is similar to other studies in developing countries, with RHD being the most prevalent. There is a need for increased emphasis on primary prevention to reduce the burden of these diseases in the study area.

Update on diagnosis of acute rheumatic fever: 2015 Jones criteria

In the final Jones criteria, different diagnostic criteria were established for the diagnosis of acute rheumatic fever for low risk and moderate-high risk populations. Turkey was found to be compatible with moderate-high risk populations as a result of regional screenings performed in terms of acute rheumatic fever and rheumatic heart disease. The changes in the diagnostic criteria for low-risk populations include subclinical carditis found on echocardiogram as a major criterion in addition to carditis found clinically and a body temperature of 38.5°C and above as a minor criterion. In moderate-high risk populations including Turkey, subclinical carditis found on echocardiogram in addition to clinical carditis is used as a major criterion as a new amendment. In addition, aseptic monoarthritis and polyarthralgia are used as major criteria in addition to migratory arthritis and monoarhtralgia is used as a minor criterion among joint findings. However, differentiation of subclinical carditis from physiological valve regurgitation found in healthy individuals and exclusion of other diseases involving joints when aseptic monoarthritis and polyarthralgia are used as major criteria are very important. In addition, a body temperature of 38°C and above and an erythrocyte sedimentation rate of 30 mm/h and above have been accepted as minor criteria. The diagnostic criteria for the first attack have not been changed; three minor findings have been accepted in presence of previous sterptococcal infection in addition to the old cirteria for recurrent attacks. In the final Jones criteria, it has been recommended that patients who do not fully meet the diagnostic criteria of acute rheumatic fever should be treated as acute rheumatic fever if another diagnosis is not considered and should be followed up with benzathine penicilin prophylaxis for 12 months. It has been decided that these patients be evaluated 12 months later and a decision for continuation or discontinuation of prophylaxis should be made. In countries where the disease is prevalent, it is very important for physicians to make an accurate diagnosis of acute rheumatic fever with their own logic and assessment in addition to the criteria proposed.

Effectiveness of Percutaneous Balloon Mitral Valvuloplasty for Rheumatic Mitral Stenosis with Mild to Severe Mitral Regurgitation

This study is designed to test whether percutaneous balloon mitral valvuloplasty (PBMV) is effective for rheumatic mitral stenosis in Chinese patients with moderate to severe mitral regurgitation. Fifty-six patients with rheumatic mitral valve stenosis were divided into the mild, moderate, and severe regurgitation groups. Cardiac ultrasonography was measured before and 1 to 2 days after PBMV. Following PBMV, the mitral orifice was enlarged, and the left atrial diameter was reduced in the 3 patient groups. The enlargement of the mitral orifice in the mild regurgitation group was greater than that observed in the moderate and severe regurgitation groups. The size of the regurgitation area increased in the mild regurgitation group and decreased in the moderate and severe regurgitation groups, with the decrease in the severe regurgitation group being greater than that in the moderate regurgitation group. Therefore, PBMV is effective for treating rheumatic mitral stenosis in Chinese patients with mild to severe mitral regurgitation.

Infective endocarditis

Infective endocarditis occurs worldwide, and is defined by infection of a native or prosthetic heart valve, the endocardial surface, or an indwelling cardiac device. The causes and epidemiology of the disease have evolved in recent decades with a doubling of the average patient age and an increased prevalence in patients with indwelling cardiac devices. The microbiology of the disease has also changed, and staphylococci, most often associated with health-care contact and invasive procedures, have overtaken streptococci as the most common cause of the disease. Although novel diagnostic and therapeutic strategies have emerged, 1 year mortality has not improved and remains at 30%, which is worse than for many cancers. Logistical barriers and an absence of randomised trials hinder clinical management, and longstanding controversies such as use of antibiotic prophylaxis remain unresolved. In this Seminar, we discuss clinical practice, controversies, and strategies needed to target this potentially devastating disease.

Rheumatic heart disease in Africa: is there a role for genetic studies?

Rheumatic heart disease (RHD) constitutes a leading cause of premature death and incapacity in Africa, where it is encountered in younger people, and shows a much faster and more malignant course than that seen in Europe or North America. While it is well established that RHD is a consequence of recurrent, untreated group A β-haemolytic streptococcal infections (GAS), the pathogenesis is incompletely understood, and the variation in natural history and phenotypes are not fully explained. In Africa patients are rarely diagnosed with acute rheumatic fever (ARF). They usually present in the late stages of RHD, with the severe and virulent forms occurring at early ages, therefore leading to high morbidity and mortality in young patients.

Neuropsychiatric manifestations of Sydenham's chorea: a systematic review

AIM

Sydenham's chorea is a post-streptococcal, autoimmune, neuropsychiatric movement disorder. Sydenham's chorea is a major criterion for diagnosis of acute rheumatic fever with the implication of potential long-term sequelae including cardiac complications. It is well established that there is psychiatric comorbidity in Sydenham's chorea, but there are variations in the literature regarding the nature and prevalence of psychiatric diagnoses associated with Sydenham's chorea. The aim of this review was to systematically evaluate the evidence for psychiatric symptoms presenting with Sydenham's chorea. Knowledge of comorbid psychiatric symptomatology will support early diagnosis and treatment, leading to improved long-term outcomes for children with Sydenham's chorea.

METHOD

The study used a systematic search strategy, using MEDLINE, MEDLINE in Process, EMBASE, and The Cochrane Library. Abstracts were screened to identify relevant papers which were then assessed further. Eligible papers were summarized.

RESULTS

A total of 1429 abstracts of relevant studies were found, and 49 papers reporting neuropsychiatric symptoms in Sydenham's chorea were summarized. Obsessive-compulsive disorder was the most commonly studied, and hence reported, neuropsychiatric symptom in children with Sydenham's chorea. The studies analysed used a variety of tools to identify affected children and used different methods for analysing results. Attention-deficit-hyperactivity disorder, affective disorders, tic disorders, executive function disturbances, and psychotic features were also reported as comorbidities.

INTERPRETATION

There is good evidence of neuropsychiatric comorbidities in Sydenham's chorea. In countries with a high prevalence of rheumatic fever, the early recognition of salient cognitive and psychiatric symptoms may aid in the management of Sydenham's chorea.

Rheumatic fever and rheumatic heart disease in Bangladesh: A review

Rheumatic fever (RF) and rheumatic heart disease (RHD) are the most-common cardiovascular disease in young people aged <25 years, globally. They are important contributors to cardiovascular morbidity and mortality in Bangladesh. Classical risk factors, i.e. poverty, overcrowding, ignorance, and insufficient health care services were responsible for the high incidence and prevalence of these diseases over the last century. In concert with the progresses in socioeconomic indicators, advances in health sectors, improved public awareness, and antibiotic prophylaxis, acute RF came into control. However, chronic RHD continues to be prevalent, and the actual disease burden may be much higher. RHD predominantly affects the young adults, seriously incapacitates them, follows a protracted course, gets complicated because of delayed diagnosis and is sometimes maltreated. The treatment is often palliative and expensive. Large-scale epidemiological and clinical researches are needed to formulate evidence-based national policy to tackle this important public health issue in future.

IL10 Promoter Polymorphisms are Associated with Rheumatic Heart Disease in Saudi Arabian Patients

Rheumatic heart disease (RHD) is an inflammatory disease that develops following streptococcal infections. IL10 helps to balance immune responses to pathogens. IL10 polymorphisms have been associated with RHD, although results remain inconclusive. Our aim was to investigate the association between IL10 polymorphisms and RHD in Saudi Arabian patients. IL10 promoter polymorphisms (-1082A/G, -829C/T, and -592C/A) were genotyped in 118 RHD patients and 200 matched controls using the TaqMan allelic discrimination assay. There was a significant difference in IL10-1082 genotype frequency between patients and controls (p = 0.01). -1082G allele carriage (GG+GA vs AA) and the (-1082, -819, -592) GCC haplotype carriage were associated with an increased risk of RHD (p = 0.004, OR 2.1, 95% CIs 1.7-3.4 and p = 0.004, OR 2, 95% CIs 1.3-3.4, respectively). The ACC haplotype was associated with a decrease in RHD risk (p = 0.015, OR 0.6, 95% CIs 0.4-0.9). IL10 promoter polymorphisms may play an important role in the development of RHD and provide an opportunity for therapeutic stratification.

Acute rheumatic fever in First Nations communities in northwestern Ontario: Social determinants of health "bite the heart"

OBJECTIVE

To document a case series of 8 young First Nations patients diagnosed with acute rheumatic fever (ARF), a preventable disease that resulted in the death of 2 patients, in northwestern Ontario in the context of late diagnosis, overcrowded housing, and inadequate public health response.

DESIGN

Retrospective case series over an 18-month period.

SETTING

Remote First Nations communities in northwestern Ontario.

PARTICIPANTS

Eight patients with ARF.

MAIN OUTCOME MEASURES

Incidence, mortality, residual rheumatic heart disease, time to diagnosis, barriers to diagnosis and treatment, housing situation of patients, patient demographic characteristics (age, sex), and investigation results.

RESULTS

The incidence of ARF in this population was 21.3 per 100,000, which is 75 times greater than the overall Canadian estimated incidence. The average patient age was 9.4 years. Most cases developed joint findings, and 5 of the surviving patients had rheumatic heart disease when they received echocardiography. The average time to diagnosis was 88 days. Two 4-year-old children died from ARF. Most patients lived in inadequate and crowded housing.

CONCLUSION

This rare disease still exists in remote First Nations communities. These communities demonstrate an incidence equal to that in aboriginal communities in Australia and New Zealand, which have among the highest international incidence of ARF. Primordial prevention, including improved on-reserve housing, is urgently needed. Case detection and ongoing surveillance for primary and secondary prophylaxis requires a well resourced regional strategy.

Acute Rheumatic Carditis: A Rare Cause for Reversible Complete Heart Block

A previously healthy 18-year-old man presented to the emergency department with weakness, fever, and joint pains and was found to have complete heart block with transient asystole requiring urgent transvenous pacing. After further workup, the patient was found to have complete heart block secondary to acute rheumatic carditis. The conduction system recovered in a step-wise fashion following treatment with Penicillin, and high dose Aspirin, without the need for permanent pacemaker placement. This case illustrates that acute rheumatic carditis, although rare, can present with advanced conduction system involvement, which is reversible if treatment is initiated.